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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~iki3h BIOI.k!3~RENT SURNAME
USE
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
COUNTY DLltchess
CITYfTOWN \^'appinger
~~~~kc: 1 368
~~~I~;~R 1 02
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 057 -60-7635
2. RESIDENCE A. NV B r'I. ,t,..hess
(STATE) '1'Cl:li51'ftY1
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 8 Brothers Rn(:ld ZIP 1 ?Fiqn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MO~ /D1~ /y1i75
3. A AGE 33
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Security
B. TYPE OF INDUSTRY OR BUSINESS Secllrity
5. PLACE OF BIRTH ~IW!;t*l'E l'ilcXNTRY IF NOT USA)
6. FATHER
A. NAME Hesikiah Frazier
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME JoeAnn BIOllnt
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
lD. 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
w
en
z
w
o
:J
~
{ SEAL }
'-v-I
NAME (PRINT)
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
4.lver. ~~ronda Ttt@WM~URNAME
.-J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Qlount
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER n71-FiR-qqFiFi
12. RESIDENCE A. NY B. Dlltl"h~ss
(STATE) TC~N-t?)
C CHECK ONE 0 CITY QI TOWN 0 VILLAGE
AND \AI .
SPECIFY applnCJ~r
D. STREET ADDREssR Rrnther~ RO:=ld ZIP 1 /590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 36 3B. DATE OF BIRTH Q~TH ~ ty /(" ~lJ
14. EMPLOYMENT
A. USUAL OCCUPATION Clerk
B. TYPE OF INDUSTRY OR BUSINESS I JSPS
15. PLACE OF BIRTH I\IInl mt \/F!rnnn NY
(CITY. STATE / COUNTRY IF NOT USA)
16, FATHER
,A. NAME Floyd Thomas
B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME H~rriF!ttp. r.lp.mp.ntin~ .I~rvi~
B. COUNTRY OF BIRTHI J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
o
o
22. SIGNATURE OF BRIDE~
DATE
08106/2008
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
07:08PM
08
07 - 2008
10
05 2008
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~/'(!)/I;('
C, LOCATION OF CEREMONY
(C~CK ONE AND SPECIFY)
a;;( CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY !lew lor K
I