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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Melchester Harold Smith
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~ 1368
~~~I~;~R 39
1 . A FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 6 15 33
D SOCIAL SECURITY NUMBER 22 - -42
2, RESIDENCE A, NY B. Oranae
(STATE) (CDUN'R'!"
C CHECK ONE -tI CITY D TOWN D VILLAGE
~~~CIFY Middletown
D STREET ADDRESS 39 Imperial Park Dr. ZIP 10941
E, is RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VilLAGE? ri YES D NO
3. A AGE 31 3B, DATE OF BIRTH 02 / 09 / 1977
MONTH DAY YEAR
4, EMPLOYMENT
A USUAL OCCUPATION Barber
B, TYPE OF INDUSTRY OR BUSINESS Hair Care
5. PLACE OF BIRTH Mecklenburg County, Virginia
(CITY, STATE / COUNTRY IF NOT USA)
6, FATHER
A NAME Chester Parham
B, COUNTRY OF BIRTH USA
7, MOTHER
A MAiDEN NAME Mabel Sue Smith
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
DEATH
o
B, HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
C, DATE LAST MARRIAGE ENDED?
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)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Keisha Lorraine Miles
MIDDLE CURRENT SURNAME
11 A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Miles-Smith
(OPTIONAL. SEE REVERSE) 102-76-4706
D. SOCIAL SECURITY NUMBER
12, RESIDENCE A, NY B. Dutchess
(STATE) (COUNTY)
C CHECK ONE D CITY l""l TOWN D VILLAGE
~~~CIFY Fishkill
D, STREET ADDRESS 74 Highland Court
ZIP 12524
D YES~ NO
/1'978
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13, A, AGE 29 3B, DATE OF BIRTH 11 /23
YEAR
MONTH
DAY
14, EMPLOYMENT
A, USUAL OCCUPATION Consultant
B, TYPE OF INDUSTRY OR BUSINESS Information Technology
15, PLACE OF BIRTH E'lrookIYII, NY
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A, NAME Wesley C. Miles
'B, COUNTRY OF BIRTHU S A
17 MOTHER
A, MAIDEN NAME Joan Stephenson
B, COUNTRY OF BIRTHDominica
18, NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B, HOW DID LAST MARRIAGE END?
(3) D DIVORCE
(3) D ANNULMENT (2) D DEATH
/ /
- YEAR
C, DATE LAST MARRIAGE ENDED?
MONTH DAY
D, ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
a:
W
III
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D D 1ST D D
D D ~D D D
D D ~D D D
D D 4TH D D
~Iedge and belief that the information 1 provided is tru:;9f )hat,I,.~clare ~hat no legai impediment exists
22, SIGNATURE OF BRIDE ~ /.( ;/ ~
"N^M~ USE CURRENT NAME
DATE 04/30/2008
21. SIGNATV8!": 9F@RQ9M,
23, SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y. k State of he 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,
D 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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best of
as to my right to enter into the m nage state,
,-A-..
{ SEAL }
'-v-I
NAME (PRINT)
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
n
ITY
26, SOLEMNIZATION OCCURRED
TIME MO, DAY YEAR
11:15 M cD
04/30/2008
NY 12590
STATE ZIP
27, TYPE OF CEREMONY
0)!1 RELIGIOUS
9 D OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
JL..I-og
29,OFFICIANT ~o d I A~
NAME (PRINT) T\o.. n10n -J... r TITLE
SIGNATURE~ _ .... :r -=-_~ DATE
MAILING ADDRESS
~.2. MuJberr-JSf''-J Mi~~)e..-J-(Jwn I
STREET t CITYfTOWN '
/'0 -
NY
STATE
AM
05:51 PM
05
01
2008
06
29 2008
1 D CIVIL
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B, COUNTY~
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF )&1. TOWN OF D VILLAGE OF
SPECIFY N e...w W j nd..s. 01
M ; n ;.s +p r
JL.J-O~
JO 9 '-10
31,
NAME (PRINT)
SIGNATURE~