091
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
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1. ,.,. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 11 A-6A-?Fi?R
2. RESIDENCE A. N';(TATE) B. ~~~;^/rence
C. CHECK ONE 0 CITY QI TOWN 0 VILLAGE
~~~CIFY Weddil1CJton
D. STREET ADDRESS ? 11 Tiprn::ln RrI ZIP 13fi!=J4
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES \tJ NO
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3. A. AGE 27
4. EMPLOYMENT
A. USUAL OCCUPATION Infantry
B. TYPE OF INDUSTRY OR BUSINESS Army N::lt'l (;11::lrrl
5. PLACE OF BIRTH O+Jrlpnl::.nll~ NY
(CI ,STATE I COUN IF NOT USA)
6. FATHER
A. NAME Terry Da\lid Wright
B. COUNTRY OF BIRTH I I S A
3B. DATE OF BIRTH
7. MOTHER
A. MAIDEN NAME nnnn::l I pp StP\lpnl::.
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
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D.ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. 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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.Kric:tin Ann Ferris
~UL:E CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. s~~~~~JN~r-~~~t~~b~~sX'Jright
D. SOCIAL SECURITY NUMBER 11 3-Fifi-41 !14
12. RESIDENCE A. N~STATE) 8. S~c~rence
C CHECK ONE 0 CITY !;il TOWN 0 VILLAGE
~~~CIFY W::lrlrlingtnn
D STREET ADDRESS 211 Tiernan Rd ZIP 13694
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 25 3B. DATE OF BIRTH J~TH /()gAY /'f ~EW
14. EMPLOYMENT
A. USUAL OCCUPATION "Ii Irl::.p
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH r.nrtl::mrlt NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME lay n::l\/irl Fprril::.
'B COUNTRY OF BIRTH lJ S A
17. MOTHER
A. MAIDEN NAME r.ynthi::! .Io-Ann r.1::!rk
B. COUNTRY OF BIRTH L J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
n
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
22. SIGNATURE OF BRIO
o 0
o 0
o 0
o 0
I impediment exists
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1ST
2ND
3RD
4TH
I duiy swear/affirm, depose and::zat to the best of m
as to my right to enter into the. rna state.
21. SIGNATURE OF GROOM~ -
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the information I provided i
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFO
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in Newark 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
~
{ SEAL }
'-v-I
NAME (PRINT)
07/16/2008
by New York Domestic
TIME
MONTH
DAY
YEAR
MONTH
YEAR
AM
05:28PM
14 2008
07
17
2008
09
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
1~VIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B.COUNTY~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY f/ yd e /tLr k,
:: p~ ~;f
rv;;t; /~.:? D
WN
29. OFFICIANT fr\
NAME (PRINT) I , \
SIGNATURE~ l.tli; / flIl.. / ~
M?G f1~S ~' ~/
~TREET ;;p~1- .~~~)~< FMr5
30. WITNESS TO CE ~ 0") / _
NAME (PRINT) /-f;1tI'[
SIGNATURE~
SIGNATUR