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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JLlstkQ,D&\Ierett DI H3M~SURNAME
COUNTY nLJtchp.l';l';
CITYffOWN W;:lppingp.r
~~~~~CRT 1 :\RR
~~~I:~~R :\7
1 A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER Fi??- 7 Fi-:\FiR?
2. RESIDENCE A. N~TATE) B. qJoifl~e
C. CHECK ONE 0 CITY J[] TOWN 0 VILLAGE
~~~CIFY New \^'il1dsnr
D STREET ADDRESS R O;:lk nrivp. ZIP 12553
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3 A AGE 21 38. DATE OF BIRTH MOQ~ / 1~ / ~~R87
4. EMPLOYMENT
A, USUAL OCCUPATION Carpenter
B. TYPE OF INDUSTRY OR BUSINESS Kirr.hoff r.nnc:;tn Ir.tinn
5. PLACE OF BIRTH ?c~rJJn~/'c~S~~I~~g~SA)
6. FATHER
A NAME Tommy Dean Duncan
8. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME Mary Elizabeth Cosh
8. 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
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
I il';;:l Marip. Rennett
MIDDLE CURRENT SURNAME
~
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(2) 0 DEATH
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE nllnr.::Jn
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 117-76-8995
12 RESIDENCE ANY 8. nLJtchp.l';S
(STATE) (COUNTY)
C. CHECK ONE 0 CITY oli"I TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREETADDREss12 Arbor Hill Drive
13. A AGE 20
OR
MONTH
ZIP 12603
DYES 00 NO
/1'~R7
YEAR
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
A14
DAY
38. DATE OF BIRTH
14. EMPLOYMENT
A, USUAL OCCUPATION Ar.r.nl mting Assil';tant
8. TYPE OF INDUSTRY OR BUSINESS Non Profit
15. PLACE OF BIRTH ~!SY s~~fcg~T~Y~FkN~~gA7ie, New York
16. FATHER
A. NAME [)o\lirl IlIrir.k RF!nnF!tt
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A MAIDEN NAME Kathryn Marie Meenagh
B. COUNTRY OF BIRTHLJ 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
MONTH DAY
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
(2) 0 DEATH
YEAR
~
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
1ST 0 0 1ST 0 0
",. 2ND 0 0 2ND 0 0
w
~ 3RD 0 0 3RD 0 0
::;)
;; 4TH 0 0 4TH 0 0
~ I duly swear/affirm, depose and saYI that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impedimen exists
~ as to my right to enter into the marnage te. _.:;.
'"
t; 21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
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This license authorizes the marriage in New rk 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
23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR CI
~
~
{ SEAL }
~
NAME (PRINT)
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
DATE
04/25/2008
AM
01 :21 PM
26
2008
06
24 2008
04
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SA
27. TYPE OF CEREMONY
YEAR 0 ~RELlGIOUS
0<6 90 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY bu.\O{.~~
TITLE N\.l tV lSTe' ft
DATE~ - ::>...'l-O'X
~irE \6S~~
31. WITNESS TO C,EREMONY
o
Y
26. SOLEMNIZATION OCCURRED
TIME MO. DAY
AM , I '"""'l
"3 .~PM "-t 2- I
~~~t~~~~T~.j lHN 'D \J~~.'
SIGNATURE~_)ib.\0 \.~
MAILING ADDRESS .
1'4 .pe.Te~.:uf'." ~t'I~ c::u l i ~
STREET CITYfTOWN
30. WITNESS TO CEREMONY "'-
NAME (PRINT) C hV', -..-\npN.V' ~\)\'\.C..~
f. vL
ZIP
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~6t-\-K- .-e..e..V'S "( €'.-J
NAME (PRINT)
SIGNATURE~