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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~: 1 368
~~~I;~~R 64
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Keith Crowell
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sarah Elizabeth Carroll
MIDDLE CURRENT SURNAME
.-J
1. . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Crowell
(OPTIONAL. SEE REVERSEb61 62 4070
D. SOCIAL SECURITY NUMBER --
12 RESIDENCE ANC B.Guilford
(STATE) (COUNTY)
C. CHECK ONE 0 CITYotJ TOWN 0 VILLAGE
~~~cIFYHiqh Point
D STREET ADDRES~931 Cobblestone Bend
ZIP27265
o YES~ NO
%976
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE),..
D. SOCIAL SECURITY NUMBER L.37 -33-9215
2 RESIDENCE A, NC B Guilford
(STATE) (COUNTY)
C CHECK ONE 0 CITY..o TOWN 0 VILLAGE
~~~CIFY High Point
D STREET ADDRESS 3931 Cobblestone Bend ZIP 27265
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"6 NO
03 /24 /1969
MONTH DAY YEAR
3. A. AGE39
38. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE31 3B. DATE OF BIRTH 08 ".(12
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Sleep Technician
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTHCity Of Pouqhkeepsie, NY
(CITY, STATE / COUNTRY IF NOT USA)
4. EMPLOYMENT
A USUAL OCCUPATION Banking
B. TYPE OF INDUSTRY OR BUSINESS Financial
5. PLACE OF BIRTH Jacksonville. North Carolina
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME James Kenneth Crowell Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Gloria Maxine Miller
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
16. FATHER
A. NAMEPaul Anthony Carroll
'B. COUNTRY OF BIRTJ-l S A
17. MOTHER
A, MAIDEN NAME Elizabeth Ann Kmiec
B, COUNTRY OF BIRTJ-l S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY,IF NOT USA) SELF SPOUSE
1ST 0 0
2ND 0 0
3RD 0 0
~ 0 0
information I provided is true and that t dect<ye that no legal impediment exists
22, SIGNATURE OF BRIDE~~/JA:iA'1 ~
USE CURRENT NAME
DATE 06/09/2008
o
o
o
o
o
o
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE
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
} NAME (PRINT) Jo n C. Masterson
{ C TIME MONTH YEAR
SEAL SIGNATURE.' DATE 06/09/2008
'-..t-I MA~I~1Oflgrdr~ ush Rd, Wappingers Falls, NY 12590 08:59 ~~ 06 10 2008
STREET CITYITOWN STATE ZIP
~~~R~:RT~~~ IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY. YEAR 0 Jll RELIGIOUS
DATE AND AT THE TIME AND AM tJ 8
PLACE INDICATED PM e:, 7 6, c) 9 0 OTHER, SPECIFY
by New York Domestic
MONTH
YEAR
08
08 2008
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED ~
A. STATE NEW YORK B. COUNTY t:>-.. <
C. LOCATION OF CEREMONY .
(CHECK ONE AND SPECIFY) t., 51 F/$Hl</Ll
29. OFFICIANT
NAME (PRINT)
o CITY O:,ZTOWN OF 0 VILLAGE OF ~'
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