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COUNTYDlltr.hp~~
CITYfTOWNW::lrring1'!r
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.J
L 0 SUPPLEMENTAL FILE
1. A. FUll NAME
-l,~!;!.p B FllisotJuRRENT SURNAME
FROM THE BRIDE
Patricia Ann Lamar
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENTMnr;:JV1'!t7
C. SURNAME AFTER MARRIAGE Flli~nn
(OPTIONAL - SEE REVERSE... 0
D SOCIAL SECURITY NUMBER :::>78-46-276
12. RESIDENCE ANY B Dutchess
(ST A TEl (COUNlYl
C. CHECK ONE 0 CITY oCI TOWN 0 VILLAGE
~~~CIFYWappinger
D. STREET ADDRES~ Peqqy Lane
11. A. FUll NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURllY NUMBER OR?-??-4127
2. RESIDENCE A. NXSTATEI B. q~~~f~~
C. CHECK ONE 0 CITY.,.[] TOWN 0 VilLAGE
AND \^' .
SPECIFY ::lrrlng1'!r
D. STREET ADDRESS 9 Peggy Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? 0 YES~ NO
3. A. AGE 81 3B. DATE OF BIRTH M~ / gA~ / ~E~?7
4. EMPLOYMENT
A USUAL OCCUPATION Retirerl
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Hnhnk1'!n N1'!W .Jer~1'!Y
(CllY, STATE / C6UNTRY IF NOT USA)
6. FATHER
A. NAME Howard Hall Ellisnn
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME M::lrg;:Jr1'!t Ringh;:Jm
B. COUNTRY OF BIRTH Ir1'!l;:Jnd
8. NUMBER OF THIS MARRIAGE 2
ZIP 12590
o YES"D NO
/1'936
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILlAGE?
13. A. AGE 7? 3B. DATE OF BIRTH 04 ~5
MONTH DAY
14. EMPLOYMENT
A USUAL OCCUPATIONRetired
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTHKnoxville. Tn.
(CllY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMERobert Louis Moravetz
'B. COUNTRY OF BIRTt-U S A
17. MOTHER
A MAIDEN NAME Myrtle Marie Post
B. COUNTRY OF BIRTt-U S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DEATH DIVORCE CIVIL ANNULMENT
1 1 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) !!1 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05/ 20 / 2001 C. DATE LAST MARRIAGE ENDED? 08 / 06 / 2002
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES f'!1 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ii1 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) (CllY/COUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CllY/COUNlY, STATElCOUNTRY, IF NOT USAI SELF SPOUSE
o 0 1ST 08/06/2002 Oranqe County, New York 0 tJ
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
of,i: _k~ and belief that the information I provi d is true ~~~,I ~eClaa no leg~edimen~exists
U,Q ~ 22. SIGNATURE OF BRIDE ~ ~ ~ ~
ME USE CURRENT NAME
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the b
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~
DATE
09/11/2008
23. SUBSCRIBED AND SWORN TO/AFFIRMED B
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
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DATE 09/11/2008
ers Falls NY 12590
WN STATE ZIP
27. TYPE OF CEREMONY
o ~RELlGIOUS
o OTHER, SPECIFY
AM
02:35PM 09
12
2008
11
10 2008
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. COUNTY OR.ANbE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
fZ CITY OF 0 TOWN OF 0 VilLAGE OF
SPECIFY M f'DbLE'l-ow ,:J
10 CIVil
29. OFFICIANT
NAME (PRINT)
31. WITNESS TO CMY 5 '1
NAME (PRINT) - ~~ .~,-"",.v,~ eO e r
SIGNATURE~ ~~