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COUNTY DlltChE'5S
CITYfTOWN \N8IrrinOpr
~~J~~c: 13RR
~5~'~~~R R~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
D\N~tltl~ Msblric~ ~~URNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
f\licoleMJDWlya Thon:JR~~flsuRNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~~J~r~~rt~~~~~stilicks
D SOCIAL SECURITY NUMBER nR~-R4-47R4
12. RESIDENCE A. NY
(STATE)
C. CHECK ONE 0 CITY ~
AND \N .
SPECIFY ~rrlnoPr
D. STREET ADDRESS 1 Robinson Gardens Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 30 38. DATE OF BIRTH g~TH ~iAY ~ ~Z~
C. SURNAME AFTER MARRIAGE
(OPTIONAL . SEE REVERSE)
D. SOCIALSECURITYNUMBER 267-91-6593
2. RESIDENCE A. NY B. n, Itf'h~5I51
(STATE) "r!5~
C. CHECK ONE 0 CITY l,;il TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 1 Rnhin!=:nn C:;~rrlpn!=: nr
B. DI&b~ss
TOWN 0 VILLAGE
3. A. AGE 33
4. EMPLOYMENT
A. USUAL OCCUPATION Senior !>dminitrator
B. TYPE OF INDUSTRY OR BUSINESS Rpt~il
5. PLACE OF BIRTH D'I\/a~ FI
(CITY, STA / COUNTRY IF NOT USA)
6. FATHER
ZIP 1 ?f)~n
YES ~ NO
/yli75
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MO~ / DQ~
3B. DATE OF BIRTH
14. EMPLOYMENIT
A. USUAL OCCUPATION NI !rc::p
B. TYPE OF INDUSTRY OR BUSINESS HBalth Care
15. PLACE OF BIRTH MT VBrnnn NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Briar Thnmp!=:nn
'B. COUNTRY OF BIRTH.Jamaica
17. MOTHER
A. MAIDEN NAME S::lnrlra TraCBY
B. COUNTRY OF BIRTH.lam::lica
18. NUMBER OFTHIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
(3) 0 DIVORCE
A NAME Edglilr Lee Hick$ Ir
B. COUNTRY OF BIRTH I I ~ A
7. MOTHER
A. MAIDEN NAME nphrn~h I pp Inhn!=:nn
8. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
DEATH
n
1
o
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 12/ 1 9 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~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
1?/1~/?nnn S~nt~ Rn~p. r.OImty, FI 0 ~ 1ST
o 0 2ND
o 0 3RD
o 0 4TH
wledge and belief that the information I provided is tru
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
(2) 0 DEATH
?noo
YEAR
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the m
W
UJ
Z
W
U
:;
23. SUBSCRIBED AND' SWORN 'O/AFFI ED BEF
SIGNATURE OF TOWN OR C TY RK
This license authorizes the marria in New York State of the bride and groom named above by any person authorized
Relations Law ~11 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 second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
08/11/2009
?-->-
by New York Domestic
~
{ SEAL }
'-.t-I
NAME (PRINT)
MONTH
YEAR
TIME
MONTH
DAY
YEAR
11 :22AM
PM
12
2009
10
10 2009
08
28. PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B. COUNTY W;SIl:lt-BfG
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF tI fOWN OF
"'.
o VILLAGE OF
~ox:.t\GLLG .;.
~.~~
SPECIFY
!UGW
31. WITNESS TO
(
SIGNATURE~
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~