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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~ 1368
~~~~;~R 45
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
r,IAnrnv r,AnrgA Morri!=:
MIDrn:E CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Maureen Walls
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11 A FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT RAnj~min
C SURNAME AFTER MARRIAGE Morris
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 583-23-9510
12. RESIDENCE ANY B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ii"I TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 16C White Gate Drive
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY
(STATE)
C CHECK ONE 0 CITY ~
AND W .
SPECIFY ~rrlngAr
D. STREET ADDRESS 16C White Gate Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..a NO
n1 /O~ /1q54
MOliTH DAY YEAR
N(A.:
B. nlltr.hA!=:!=:
(COUNTY)
TOWN 0 VILLAGE
ZIP 12590
DYES tJ NO
,,1953
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE !=i4 3B. DATE OF BIRTH 11 /02
MONTH DAY
3. A. AGE 54
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION LahnrAr
8. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH AleiArton .I~m~ir.~
(CITY. STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Certified Nursing Assistant
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Trinidad And Tobago
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Ilnl<:rl0\~/n
B. COUNTRY OF BIRTH llnknown
7. MOTHER
A. MAIDEN NAME Ivy R~rrAtt
B. COUNTRY OF BIRTH .I::lm::lir.::l
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
16. FATHER
A. NAME Vernon Renjamin
'B COUNTRY OF BIRTH Trinidad And Tobago
17. MOTHER
A. MAIDEN NAME Cynthia Joseph
8. COUNTRY OF BIRTH Trinidad And Tobago
18. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
? 0
DEATH
o
DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH 8. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
/ / C. DATE LAST MARRIAGE ENDED? 09 / 05 / 2007
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE{S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? [!l"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 0 0 1ST 09/05/2007 Westchester County, NY 0 r!l'
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
J duly swear/affirm, depose and sa I that to the best of my knowl dge d belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the m la~e state. '
21. SIGNATURE OF GROOM~ I , ~~ 22. SIGNATURE OF BRIDE~O,' b <>---' v-..--Z (~~ ~
USE CURRENT NAME , USE CURRENT NAME
23. ~::J:T~~~Do~N.fo~~RRN ~~A~m~~ BEFORE ME DATE 05/06/2008
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law !l11 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 } SNIAGMNEAT(PuRRIEN: In~ M;:l..::trr~"nn DATE TIME MONTH YEAR MONTH
...- __ c.~ 05/06/?008
MAILING ADDRESS AM
"-v-I STR?~ MirlrllAnll!=:h Rei, W::lrg~")1d.fNr!=: F~lIs'sT~J' 1 ?59~p 12:53PM 05 07 2008 07 05 2008
~~~R~~Ri~~~ 'o~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY /'
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 I2r CIVIL
~~~E ~~gIC~;:~E TIME AND AM 5 'it Joo<<i" 9 0 OTHER, SPECIFY
~:OO
29. OFFICIANT ...-: LL C N\ 11 c_",- 0 '"
NAME (PRINT) ..JOn t"\ .,. . ~ ~ I ..."... On
SIGNATURE ~ ()f) r. -'/. L-+r:--.....
MAILING ADDRESS 0/' ~
~ MlbbL~&USe-( ttb . I,jAPP/~f~S F,HIS
STREET ' CITYfTOWN
C. DATE LAST MARRIAGE ENDED?
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY DuTcl-teS-5
TITLE fY\"ct~ll\6t
DATE ~12L;o'"
NY
SlATE
o ~t:' I c:...E" t<.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
(d5cro
ZIP
SPECIFY wit PP lo6E. fl
30. WITNESS TO CEREMONY
31. WITNESS TO CEREMONY .f) W
NAME (PRINT) S (/ S fA ~ I~ 0. _ a.... I
SIGNATURE~ ~/L]{1^--'!::tQ~
NAME (PRINT)
SIGNATURE~
M,qJ duna--Jo
A1 4LeRvr..
nflu._CR tn':ll?nnh\