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::s I A II:. UI- NI:.W YUHI\
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Michael Walls
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~~c; 1368 .
~~~I:~~R 34
1. A FULL NAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tabitha Marie Borowskv
MIDDLE CURREN'TSURNAME
~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 113-68-3028
2. RESIDENCE A. NY 8. Dutchess
(STATE) (COUNTY)
C. CHECK ONE ..0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
D. STREET ADDRESS 12 Grove St. ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
3. A. AGE 3? 38. DATE OF BIRTH 03 / 17 /1977
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Custodian
B. TYPE OF INDUSTRY OR BUSINESS Beacon School Dist
5. PLACE OF BIRTH Bronx. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John Mccarthe Walls
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Lorraine Ann Cook
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
11. A FULL NAME
FIRST
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wall s
(OPTIONAL. SEE REVERSE)064 66 0601
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~cIFYBeacon
D. STREET ADDRESS 12 Grove St.
ZIP 12508
'tJ
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE27 3B. DATE OF BIRTH 11 A 1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Transcriptionist
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTHRhinebeck, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Edward Christopher Borowskv Sr.
'B. COUNTRY OF BIRTHU S A
YES 0 NO
. )\"981
YEAR
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(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) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o
o
o
17. MOTHER
A. MAIDEN NAME Marvann Ballard
B. COUNTRY OF BIRTHU S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
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
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23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 ~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
} NAME (PRINT) Joh
{TIME MONTH YEAR
SEAL SIGNATURE ~ E 05/08/2009
MAILING ADDRESS AM
'-v-I 20 Middle ers Falls NY 12590 01:47PM 05 09 2009
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
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER. SPECIFY
21. SIGNATURE OF GROOM ~ .-'
29. OFFICIANT
NAME (PRINT)
TITLE
DATE
DATE
by New York Domestic
MONTH
YEAR
07
07 2009
28. PLACE WHERE MARRIAGE OCCURRED
1 Iil CIVIL
A. STATE NEW YORK B. COUNTY 1). L~
~
sPt ),,'1
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF JlI.l TOWN OF 0 VILLAGE OF
SPECIFY L.~/,. . h.L.c / ,- ~
t-"1
STATE