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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Chariff Abdu McMillion
23. SUBSCRIBED AND SWOR TO/AFFI 0 BEFORE ME
SIGNATURE OF TOWN OR RK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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) John C. Masterson
{, TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE~ C' "vi '. .:> DATE 01/26/2009
MAILING ADDRESS 1 0 '16AM
'-y-I 20 Middle ush Rd. Wappinaers Falls. NY 12590 . 01 27 2009 03 27 2009
STREET CITYlfOWN STATE ZIP PM
~~~R~:RT~~~ 10~O~~~N~i~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 -;;., RELIGIOUS
DATE AND AT THE TIME AND _
PLACE INDICATED. :::> ; 30 '2.00 q 9 0 OTHER. SPECIFY
TITLE 00 H \V\ l S +e. V-
DATE ;;../ /0 7
s+,,~ \ >\wJ . '{
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT1368 .
NUMBER
REGISTER 4
NUMBER
1. A. FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
0.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)07 4-58-0163
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY'tJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D STREET ADDRESS 612 Clermont Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1J NO
05 /10 /1970
DAY YEAR
3. A AGE38
38. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Trade Show Sales
8. TYPE OF INDUSTRY OR BUSINESS Marketing Decorating
5. PLACE OF BIRTH Bronx, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John Robert McMillion
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Alice Mcfadden
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
100
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12 / 23 / 2008 .
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~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
12/23/2008 Westchester. Nv cl 0
o 0
o 0
21. SIGNATURE OF GROOM
29. OFFICIANT
NAME (PRINT)
(1"/':> C1,...I1l"C: rUM .:>I.M/C v,::,r: U/YL..Tj
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melany Denise Sullivan
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE M cM i II ion
(OPTIONAL. SEE REVERSEI065-58-7046
D. SOCIAL SECURITY NUMBER
12 RESIDENCEANY BDutchess
(STATE).L (COUNTY)
C. CHECK O~. 0 CITY U TOWN 0 VILLAGE
~~~CIFY rlShkll1
D. STREET ADDRESSo12 Clermont Lane
ZIP 12:J8U
DYES '6 NO
)'967
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE41 3B. DATE OF BIRTH 11 )'6
MONTH OA Y
14. EMPLOYMENT
A. USUAL OCCUPATION Accounts Receivable Manager
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15 PLACE OF BIRTH Manhattan, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Arthur Samuel Sullivan Jr.
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Joan Delores Belton
B. COUNTRY OF BIRTHU S A
18. 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) 6 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 26 / 1997
MONT!U DA Y ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? LJ 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
03/26/1997 Bronx, New York 0 t1
o 0
o 0
o 0
n9 legal impe~ent exists
//U~~ ~
DATE
01/26/2009
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY jJlrA\A '^I\.fetv\
STATE
IO~O\
ZIP
31. WITNESS TO CERE~Y
NAME (PRINT) 0
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
'7t-CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY tJ.<t.1J) Yo y-I'- C ~
SIGNATURE~