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r he Year 1 <br /> OCCUPATION PLACE OF BIRTH NAMES OF PARENTS OF EACH NAME, RESIDENCE AND <br /> OF EACH OF EACH OFFICIAL STATION OF PERSON DATE OF <br /> (Give Full Name of Father and Maiden Name of Mother) RECORD <br /> BY WHOM MARRIED <br /> I <br /> r- <br /> 1 <br /> I <br />+ f <br /> is <br /> I <br /> —Pa <br /> ZZ <br /> 06 <br /> f + <br /> r I TYPE WITH <br /> AFFIDAVIT PERMANENT „z J <br /> BLACK INK. " <br /> ALL ADDITIONS AND CORRECTIONS MUST BE SUBSTANTIATED THIS IS A <br /> BY WRITTEN EVIDENCE(M.G.L.CHAP.46,SECTION 13) PERMANENT <br /> THE UNDERSIGNED,being duly sworn,depose and say under penalties of perjury that the record relating to the marriage RECORD. <br /> i of�HP� �''IAI R DF'r�AIAF and RTiC1T _A Tn KTTNSFT,MAN in <br /> QQ (Gi name o par y exact y as recorded on§ie ongtnarrecci (Give name of party exactly as recorded on the original record) , <br /> the city or town of MASHpRR does not fully and/or correctly state data regarding: ( -" <br /> ❑ Groom*Item(s) ❑Bride*Item(s) <br /> ❑Officiant*Item(s) ❑Other*Item(s) (— <br /> *Indicate itenijiumber as it appears on the reverse of this form. <br /> NATURE RESIDENCE Either Party to <br /> City or town,street and nu ber.if any. Marriage or Relative Z y. <br /> FURTHER,the written vidence at or near the time of the marriage submitted to substantiate the affidavit was: <br /> CERTIFIED COPY OF BIRTH CERTIFICATE <br /> Then personally appeared before me the person(s)whose signature(s)appear(s)above and made <br /> -oath that the statements subscribed <br /> are true. <br /> Date: Smb a3, ! 9rt (� Name: <br /> S (Month,Day,Year) C LE93z -- I r <br /> Official designation: IOW <br /> f (City or town clerk,assistant clerk,registrar,or notary) <br /> CITY AND TOWN CLERKS MUST TRANS 1IT A COPY OF THIS RETURN TO THE <br /> COMMISSIONER OF PUBLIC HEALTH AT ONCE. <br /> � -------- <br /> 4A <br /> J�. <br />