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COUNTY DutchCGG
g~;ri~gWN \N3ppinger
~~~~~~~ 368
NUMBER 115
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ds'tlliQLl-cmucl r~TSURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jami~,obl'nn Rom~~T SURNAME
~
1. . A. FULL NAME
11. A. FUll NAME
FIRST
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTCle3r
c. SURNAME AFTER MARRIAGE Dloss
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 074-60-0729
12, RESIDENCE ANY BD' .tt"hQSS
(STATE) ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND '^/ .
SPECIFY . . applnger
D. STREET ADDRES~5 'Alidmpr Rrl ZIP1 ?~90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..t] NO
13 A. AGE39 3B. DATE OF BIRTH ~TH ~~AY -1~~
14. EMPLOYMENT
A. USUALOCCUPATIONHR Miim.ger
B. TYPE OF INDUSTRY OR BUSINESS Tr:;:lnc:::port::!tion
15. PLACE OF BIRTH~cC?,-~,I;WT~h:t~~~~F'N~~SA)
16. FATHER
,A. NAMEMicha81 Joseph Clear
B. COUNTRY OF BIRTH I S A
17. MOTHER
A. MAIDEN NAME Linda Rose Rnhinsnn
B. COUNTRY OF BIRTr4 I S A
18. NUMBER OF THIS MARRIAGE ?
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 1 011 52 2786
B.~p::;
VILLAGE
2. RESIDENCE A. ""V
r ~STATE)
C. ~~6CK ONE 0 CITY..!J TOWN 0
SPECIFY \N3ppinger
o STREET ADDRESS 25 Widmer Rd. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES<l] NO
MJ;l~ / ~Ae / ~~7
3 A AGE 41
4. EMPLOYMENT
38. DATE OF BIRTH
A. USUAL OCCUPATION ProfeGGional Driver
B TYPE OF INDUSTRY OR BUSINESS Transportation
5. PLACE OF BIRTH ttdHQ~WQ ~~
(, Ol1N Y IF NOT USA)
6. FATHER
A. NAME \/Villiam E. PloGe
B. COUNTRY OF BIRTH U ~ .A..
7. MOTHER
A. MAIDEN NAME Kathleen E. Markle
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
1
o
o
1
o
o
8. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) Iiii'f DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 05/ Div6 / ~Q06' c. DATE LAST MARRIAGE ENDED? MONTt-?2 / Q..~ . (, ~9.~8
D. ARE ANY FORMER SPOUSE(S) ALIVE? Ii,l"YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
.
1 D. 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
05/16.'2006 Kingston, Ny 0 iii!l' 1ST 02/04/2008 Pnllohkeerc:::ip, Ny &' 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
and belief that the information I provided is true and that I declare that no legal impedime:1t exists
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the m n e
21, SIGNATURE OF GROOM ~
DATE ORf?~/?OOR
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonie 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
,-'-..
{ SEAL}
'-v-I
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
AM
03:50PM 08
26
2008
10
24 2008
ZIP
l~VIL
ST
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 h uiCJ.{-€,:>(,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY WA{>PI~~~
29. OFFICIANT
NAME (PRINT)
IN
STREET CITYfTOWN
30 WITNESS TO C~EMONY ~ r~530
NAME (PRINT) ~'iY IV'l ~
SIGNATURE~ ~
STATE
NAME (PRINT)
~::a(';NATIIRF .....