127
9. ~~~~~~~RMtf~~A~Bus MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT 2~&EAJH
C. DATE LAST MARRIAGE ENDED? 11 / 22 /
MONT'i"I DAY
D. ARE ANY FORMER SPWlSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUllED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST 11/22/2006 Broome, New York [5
2ND 0
3RD 0
4TH
I duly swear/affinn. dep.ose and say, that to the best of
as to my right to enter into the marnage tate.
21. SIGNATURE OF GROOM~
U ECU
23. SUBSCRIBED AND SWORN TO/AF IRM BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law fil1 to perfonn marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jo C. Masterson
{SEAL SIGNATURE" DATE 11/12/2009 YEAR
'-v-' MAI~ AA?8E eb S, NY 12590
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Lee Jay Cobb
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN Wappinger
DISTRICT1368 '
NUMBER
REGISTER 127
NUMBER
1. A. FULL NAME
FIRST
..
I'l
B. BIRTH NAME, IF DIFFERENT
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE066 62 1822
D. SOCIAL SECURITY NUMBER - . -
2 RESIDENCE A. NY B. Dutchess
(STATE) J.... (COUNTY)
C. CHECKONE 0 CITY'U TOWN 0 VILLAGE
AND W .
SPECIFY ap~lnger .
D. STREET ADDRESS 08 Chelsea Cay
3. A. AGE43
lL:J90
ZIP
Irl
/fbS5
YEAR
Lo
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0
11 /21
DAY
3B. DATE OF BiRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
5. PLACE OF BIRTH Endicott, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME .James Earl Cobb Sr.
B, COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy Carol Post
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 2
DEdTH
YEAR
SUPPLEMENTAL FILE
FROM THEBRIDE .
Kanokporn Janlavilad
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
B. BIRTH. NAME (MAIDEN NAME)~~~~ENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL s~~ NUMBER Dutchess
12. RESIDENCE A. B.
. (STATE) Irl (COUNTY)
C. CHECK Q~ 0 CITY 0 TOWN 0 VILLAGE
AND vvapplnger .
SPECIFY 50S Ghel~ea Gay .12G90
D. STREET ADDRESS ZIP
.,
E. IS RE~'fNCE WITHIN LIMITS OF CITY OR INCORPORA~ VILLAGE?1/3 0 Y~ffO
13. A. AGE 38. DATE OF BIRTH L E
MONTH DAY YEAR
14. EMPLOYMENT
Accountant
A. USUAL OCCUPATION At'
ccoun my
B. TYPE OF INDI,I~TRY OfUl!.lli!f\lE~SPh t Tt 'I .
r\ampnaeny e lal allU
15. PLACE OF BIRTH I
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER .
Sawoey Janlavllad
A. NAME Thailand
B. COUNTRY OF BIRTH
17. MOTHER Th J
ong uer
A. MAIDEN NAME Thailand
B. COUNTRY OF BIRTH ...
L
1B. NUMBER OF THIS MARRIAGE
19. ~~~~~~~RMtlW~AEcvrBus MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A'6'ULMENT
>I
B. HOW DID LAST MARRIAGE END? (3) 0 DIVO'l5'3 (3) ~NULMENT 2~51 DEATH
c. DATE LAST MARRIAGE ENDED? / /
MONTII'" DAY, '.- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~ .
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
~~~,~O~) C~COn~u~' sni~~1rd IF NOT USA) S9-F SPOUSE
1ST 0 0
2ND 0 0
3RD 0 0
o 0
at I d~hat no legal impediment exists
USE CURRENT NAME 11/12/2009
DATE
by New York Domestic
D'CtTH
YEAR
01
11 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN..:;j;2..re: /frI.t
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o ",., 0' 0 ,ow, "" ""'~ /1.
'SPECIFY WtH/PI M1w L~
"
NAME (PRINT)
!':1r.NATIJRF~