096
~~~ W
f-~f- t-
ll!~~ .,
f- W Z ....
315m 0
::;;Cl5 u:
I-ZCIJ _
~~~ t:
lEoen w
Of->
w~C5 0
b15'"
z ~ ;:; NAME (PRINT)
SIGNATURE~
+
f-
Z
W
en
w
IX>
o
...J
=>
o
:r:
en
Z
o
>=
~. ~
en
a
w
a:
w
Cl
<
a;
a:
<
::;;
"-
o
w
!;;:
<.l
u:
>=
a:
w
<.l
w
a:
w
:r:
~
en
en
w
a:
o
o
<
1::
13
w
"-
en
+
COUNTY nlltr.hp-!,:!,:
CITYiTOWN W;:lppinger
~~~::f; 1 ~RR
~~~I~~~R ~R
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RU~I~I Hugh E~i~ SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
JacqL.IEtlb~ Nicola \Wj~Q~PJRNAME
~
1. A FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SYS~*~tfA~~~~t~~ms&agan . /
D. SOCIAL SECURITY NUMBER Nt A
12. RESIDENCE A. N~STATE) B D~Miij~ss
C. CHECK ONE 0 CITY IitI TOWN 0 VILLAGE
AND P hk .
SPECIFY 0110 p-p-p!':le
D. STREET ADDREss621 Sheafe Road; Lot 45 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
13. A. AGE 33 3B. DATE OF BIRTH g~TH /2 dAY /'j' ~JR5
14. EMPLOYMENT
A. USUAL OCCUPATION nomp!=:tir. I=nginppr
B. TYPE OF INDUSTRY OR BUSINESS Homemaker
15. PLACE OF BIRTH Newell .Iamair.a
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME TrE'\Ior GE'ra1d \Mioo~n
'B. COUNTRY OF BIRTH.Jamair.::l
17. MOTHER
A. MAIDEN NAME FV::l M::lverine Trenr.hfieln
B. COUNTRY OF BIRTH.I::lm::lir.::l
18. NUMBER OF THIS MARRIAGE 1
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL . SEE REVERSE)
o SOCIAL SECURITY NUMBER A.6?-~~-OA.O~
2 RESIDENCE A. N);TATEI B. Qb~e5s
c. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND Phi- .
SPECIFY Olla "eer!=:IP
o STREET ADDRESS R? 1 ~he::lfe RO::ln' I ot 45 ZIP 12601
.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
MO~~ / DQy1 / yl~61
3. A. AGE -17
4. EMPLOYMENT
A. USUAL OCCUPATION Laborers I Inion
B. TYPE OF INDUSTRY OR BUSINESS r.on!=:trllr.tion
5. PLACE OF BIRTH Be~r.on Nll
(CITY, STATE / COUNtRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
t-
:>
c(
c
wU:
"'u.
~c(
A. NAME RL.lssell Hllgh Eagan
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME l\JI~ro~rpt Phehp r,r~h;:lm
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
1
o
a:'
w
IX>
::;
=>
z
o
Z
<
I-
W
W
a:
t;;
o
B. HOW DID LAST MARRIAGE END? (3) I!il'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05/ n3 / 1 q85 C. DATE LAST MARRIAGE ENDED? / (.
MONTH DA~ YEAR MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? cYYES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
1ST OFiIO~/1 ~RFi T;:lrr~nt r.OI mty, Tx 0 I!il' 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, depose and sa I that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into he mar lage ~te. _ J
21. SIGNATURE OF GROOM ~ b 'L' ~ 22. SIGNATURE OF BRIDE ~J .Q r /; j/..Q,(MU, .LI../~'~~~
U E C R NT NAME V USE CURRENT NAME
23 ~::JfT~~~OO~N~O~;~Ot~ ci~A6~~RM:~ BEFORE ME . . DATE 8
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized by New York Domestic
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
w
o
z
w
o
::i
~
{ SEAL }
"-v-'
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
2008
09
28 2008
07
31
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B cou~ul\t.rf2A
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) L
o CITY OF 0 TOWN OF ~LAGE OF
'1PECIFY W~(J, ~ f~
NAME (PRINT)
SIGNATURE~