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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mon~~~~ Lavon GirIiQlilsuRNAME
COUNTY Dutchess
CITYfTOWN. 'ntappinger
DISTRICT . .
~~~I~~~R1368
NUMBER 94
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 259 45 6386
2. RESIDENCEA. "IV B. r"'. .mherland
1""1I lSTATEI '-(O(lUN~ .
C. ~~6CK ONE ~ CITY 0 TOWN 0 VILLAGE
SPECIFY F ayettevine
D. STREET ADDRESS 204 Ang&1 Oik. COlJrt; I Init ZIP 28316
E. IS RESIDENCE WITHIN LiMITS OF CITY OR INCORPORATED VILLAGE? 0121 YES 0 NO
3. A. AGE 3S 3B. DATE OF BIRTH MO~T~ / ~~ / ~73
4. EMPLOYMENT
A. USUAL OCCUPATION Pipe Foreman
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH ~~'.;u:\!:!~ G.li
'le1'T'f7 STA1~ l't::OONTIl'i"IF'NOT USA)
6. FATHER
A. NAME Thomaa JameE: Hopkins
B. COUNTRY OF BIRTH U 53 A
7. MOTHER
A. MAIDEN NAME . Josephine Green
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1
o
o
B. HOW DID LAST MARRIAGE END? (3) Iil'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 06/ no / ')()03
MONTH Diff ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? [ijly'ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
r
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Shin~r6I.ine GLI'ttbW~T SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Bills
c. s~S~~rcM~~~~t~~~~~s~reen
D. SOCIAL SECURITY NUMBER 07 t::,- 7 4-1 011
12. RESIDENCE A.NY(STATE) B.C,~~rland
C. CHECK ONE .,fJ CITY 0 TOWN 0 VILLAGE
AND E . '11
SPECIFYayettE'\I1 E'
D. STREET ADDRESD04 AngAl Oak~ CnLJrt;Unit zIP28316
E. IS RESIDENCE WITHIN LiMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 3-1 3B. DATE OF BIRTH Q,~NTH ~~AY ,{ ~l.~
14. EMPLOYMENT
A. USUAL OCCUPATION Constrl.lctionln~ppdnr
B. TYPE OF INDUSTRY OR BUSINESS ~nVArnmAnt
15. PLACE OF BIRTH~J1~nh::ltt::ln NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
,A. NAME Syr\le~ter Bills
B. COUNTRY OF BIRTHI J SA
17. MOTHER
A. MAIDEN NAME Arlri::ln Rllth WilliaQ1~
B. COUNTRY OF BIRTHl J S A
lB. NUMBER OF THIS MARRIAGE' 2
19. PREVIOUS MARRIAGES . .
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) I!I'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? OR / 01 / ?009
MONTH DAY' - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
.
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
ORIn1/?009 Savannah GA 0
o
o
22. SIGNATURE OF BAIDE ~
1ST 06/06/2003 53ivannah, Georgi.
2ND
3RD
4TH
I duly swear/affirm, aepose and S
as to my right to enter into the
o ~ 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the information I provided is tru
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized
Relations Law !l11 to perform 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 sBcond or subsequent ceremony,
24. TOWN OR CITY. CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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Z t-^-.
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~ {SEAL}
'-v-I
NAME (PRINT)
DATE 08/25/200~
by New York Domestic
TIME
MONTH
YEAR
AM
04:23PM
2009
10
24 2009
08
26
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TATE
27. TYPE OF CEREMONY
o I!1 RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B. COUNTY IJ,ACII'itr
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN.OF 0 VILLAGE OF
'f.. SPECIFy~:V&.dR
TITLE ,;t:' AS 7b /?
DATE .s;/;:l.>A~,
/f/ l/ / ,1.09C)
ST~ ZIP
31. WITNESS TO CEREMONY
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et 29 OFFICIANT ~,.. #-
~ :~GMN::~:: ~C~i/;;/~
... MAILING ADDRESS " ~ /..
a:W ~~// $'",,17; Ap6' V/A"./'/lVrI~~~~
o STREET CITYfTOWN
30. WITNESS TO CEREMONY
NAME(PRINT) T"". ". ~ ~~'f"t"V
~', '"T"
SIGNATURE~
28. PLACE WHERE MARRIAGE OCCURRED
NAME (PRINT)
SIGNATURE~