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1. A. FULL NAME
~ 11-\ II:: vr I~I:: YV 'vn~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Ste\lelJlI)'ll"mes Grift'lf~EN~rURNAME
FIRST
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dlltchess
CITYrrOWN W;::)rrinop.r
~~~:~CRT 13RR .
~5~~J~R 1 !)~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Map, Beth McCollum
JMIDDLE CURRENT SURNAME
~
11. A. FULL NAME
n.
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE C:;riffF!n
(OPTIONAL - SEE REVERSEb
D. SOCIAL SECURITY NUMBER 55-72-4450
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRES~5D Sherwood Forest
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 R-RR-R~!11
2 RESIDENCE A N'X'STATE) B. ~rss
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
AND 'AI .
SPECIFY \ appll'lop.r
D STREET ADDRESS ~5D Sherwood Forest ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
3. A. AGE25 3B. DATE OF BIRTH --.;rom / 'iJ / ~E~J32
4. EMPLOYMENT
A. USUAL OCCUPATION 'Mater Technician
B. TYPE OF INDUSTRY OR BUSINESS r.on~tn Idion
5. PLACE OF BIRTH PnllnhkF!p.n~ip,-, Nv
(CITY. stATE I COiJNTRY IF NOT OSA)
6. FATHER
A. NAME Ste\len James Grifter
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Tnni Ann M;::)rip. I aRargp.
B. COUNTRY OF BIRTH I J ~ A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
ZIP 12590
o YES "6 NO
;(980
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE?7 3B. DATE OF BIRTH 12 ~8
MONTH OA Y
14. EMPLOYMENT
A. USUAL OCCUPATION Secreta ry
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTHPouahkeepsie. Ny
(CITY, STATE' COUNTRY IF NOT USA)
16. FATHER
A. NAME Dp.nnis Harold McCollum
'B. COUNTRY OF BIRTHlJ S A
17. MOTHER
A. MAIDEN NAME Mary Ellen Tremblay
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
o
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH OA Y 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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and S
as to my right to enter into thB
21. SIGNATURE OF GROOM. '
o
o
o
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
st of my knowledge and belief thBt the information I provided is true and that I dec
22. SIGNATURE OF BRIDE.
US
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 ~11 to perlorm marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this licBnse is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
10/02/2008
by New York Domestic
,-"-..
{ SEAL }
'-.t-I
NAME (PRINT)
MONTH
TIME
MONTH
YEAR
YEAR
DATE 10/02/2008
ers Falls NY 12590
WN STATE ZIP
27. TYPE OF CEREMONY
D ~L1GIOUS
() I- 9 0 OTHER, SPECIFY
AM
03:11PM
03
2008
12
01 2008
10
in
ITV
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
10 CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYlJv lc},r:.. j {
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF
SPECIFY f, r/'/(. 1/
AM
PM
10
/1
.,.
-'
SIGNATURE
MAILING AD
Iv J
STREET
30. WITNESS TO
TITLE j( &. f I!. ,~ J
IM~ lell/fI!
DATE
rl (hI', ! / 4-') /r"~ '-f
o VILLAGE OF
IJ/
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) C A ~ ~ L
NAME (PRINT)
SIGNATURE~