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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~~T 1368 .
~E~~:~R 145
~ I A II:: Ur- NI::VV YUH~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nicholas Alexander Brown
MIDDLE CURRENT SURNAME
FIRST
-.. -. .-- ._~.------
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Karia Lakeisha Shurland
MIDDLE CURRENT SURNAME
-.l
1. A FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Shurland-Brown
(OPTIONAL. SEE REVERSE)590. -73-2054
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREETADDREss46 Townview Drive
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 121-68-0159
2. RESIDENCE A NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 46 T ownview Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"6 NO
07 /10 /1979
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Medical Biller
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH KinQston , Jamaica
(CITY, STATE / COUNTRY IF NOT USA)
ZIP 12590
o YES'(] NO
;t'977
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 31 3B. DATE OF BIRTH 09 /.:!O
MONTH DAY
3. A. AGE ?~
36. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Electrician
B TYPE OF INDUSTRY OR BUSINESS Electrical
5. PLACE OF BIRTH Brooklyn. Ny
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Marciano Alexander Brown
B. COUNTRY OF BIRTH Jamaica
7. MOTHER
A MAIDEN NAME Shirley Ann Shields
B. COUNTRY OF BIRTH Jamaica
B. NUMBER OF THIS MARRIAGE 1
16. FATHER
A. NAME Roy Shurland
'B. COUNTRY OF BIRT~amaica
17. MOTHER
A. MAIDEN NAME Patricia Wynter
B. COUNTRY OF BIRT~amaica
1B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) tj DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 02 / 15 / 2008
MONTH DAY YEAR MONT~ DAY, . ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? LJ YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o 0 1ST 02/15/2008 New York, Ny 0 ~
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
f my knowledge and belief that the information I provided is tr I impediment exists
DEATH
o
DEATH
o
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and S
as to my right to enter into the m
.I
21. SIGNATURE OF GROOM ~
DATE
09/24/2008
22. SIGNATURE OF BRIDE
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y 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) Jo n C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 09/24/2008
\- --1 MAI.l.!I)lG"~IPdREi$eS AM 9
-yo- LU IVII mush Rd, Wappingers Falls, NY 12590 05:32PM 0
STREET CITYITOWN STATE ZIP
~~~~r~RT~t~ lo~O~~~N~Zff 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY _ ./'"
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 IkrCIVIL
DATE AND AT THE TIME AND AM
PLACE INDICATED. :3: i.{S IO;1y J..oo~ 9 0 OTHER, SPECIFY
by New York Domestic
MONTH
YEAR
25
2008
11
23 2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY b~4es r
29. OFFICIANT ~r '" ~
NAME (PRINT) _~iO ~~) 1..., \:;~ ~O.
SIGNATURE~ ___j~bl~,~
MAILING ADD RES
~R~llN.\i(2J,SV\ Po ~ ~~~c"
30. WITNESS TO CEREMONY
NAME (PRINT) S
SIGNATURE~
DOH.9B (03/2006)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF lB"TOWN OF 0 VILLAGE OF
TITLE 111~ IAr;e. o{..{./c..k.ie-
DATE 1/42..(( 2do&-
N ~STATE IJ.S~9 qlP
SPECIFY
lJJ~ 11\J6E:.F--
tJ!.\l~
M
SIGNATURE~