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STATE FILE NUMBER (THIS SPACE FOR STATE USE ONLY) STATE OF NEW YORK DEPARTMENT OF HEALTH COUNTY SUPPLEMENTAL FILE AFFIDAVIT BRIDE/GROOM/SPOUSE BRIDE/GROOM/SPOUSE SPECIFY ADDRESS WHERE CERTIFICATE OF MARRIAGE REGISTRATION SHOULD BE SENT STREET AND NUMBER CITY / TOWN / VILLAGE STATE ZIP 1. A. FULL NAME I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists as to my right to enter into the marriage state. 22. SIGNATURE 4 21. SIGNATURE 4 USE CURRENT NAME 23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME SIGNATURE OF TOWN OR CITY CLERK4 DATE FIRST MIDDLE CURRENT SURNAME B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER 2. RESIDENCE A. B. C. CHECK ONE CITY TOWN VILLAGE AND SPECIFY D. STREET ADDRESS ZIP E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? YES NO 3. A. AGE B. DATE OF BIRTH C. SEX (OPTIONAL) MM/DD/YYYY 4. EMPLOYMENT 5. PLACE OF BIRTH (CITY, STATE / COUNTRY, IF NOT USA) 6. FATHER OR PARENT 7. MOTHER OR PARENT 8. NUMBER OF THIS MARRIAGE 9. PREVIOUS MARRIAGES DIVORCE: CIVIL ANNULMENT: DEATH: C. DATE LAST MARRIAGE ENDED? D. ARE ANY FORMER SPOUSE(S) ALIVE? YES NO 10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM 1ST 2ND 3RD 4TH 11. A. FULL NAME B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER USE CURRENT NAME B. HOW DID LAST MARRIAGE END? DIVORCE ANNULMENT DEATH (STATE) (COUNTY) 12. RESIDENCE A. B. (STATE) (COUNTY) MM/DD/YYYY FIRST MIDDLE CURRENT SURNAME A. USUAL OCCUPATION B. TYPE OF INDUSTRY OR BUSINESS A. NAME (OR MAIDEN NAME, IF APPLICABLE) B. COUNTRY OF BIRTH A. NAME (OR MAIDEN NAME, IF APPLICABLE) B. COUNTRY OF BIRTH A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE D. STREET ADDRESS ZIP 13. A. AGE B. DATE OF BIRTH C. SEX (OPTIONAL) MM/DD/YYYY 14. EMPLOYMENT 15. PLACE OF BIRTH (CITY, STATE / COUNTRY, IF NOT USA) 16. FATHER OR PARENT 17. MOTHER OR PARENT 18. NUMBER OF THIS MARRIAGE 19. PREVIOUS MARRIAGES DIVORCE: CIVIL ANNULMENT: DEATH: C. DATE LAST MARRIAGE ENDED? 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM 1ST 2ND 3RD 4TH A. USUAL OCCUPATION B. TYPE OF INDUSTRY OR BUSINESS A. NAME (OR MAIDEN NAME, IF APPLICABLE) B. COUNTRY OF BIRTH A. NAME (OR MAIDEN NAME, IF APPLICABLE) B. COUNTRY OF BIRTH A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE C C c C. CHECK ONE CITY TOWN VILLAGE AND SPECIFY E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? YES NO B. HOW DID LAST MARRIAGE END? DIVORCE ANNULMENT DEATH D. ARE ANY FORMER SPOUSE(S) ALIVE? YES NO AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE REGISTER NUMBER DISTRICT NUMBER CITY/TOWN MM/DD/YYYY