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~~~
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368
~~~I:~~R 34
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
r.hri!=:tnnher.1 Wilkerson
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Heather M Sherman
MIDDLE CURRENT SURNAME
~
1. . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wilker!=:nn
(OPTIONAL, SEE REVERSE)079 68 3293
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A, NY B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Stanford
D STREET ADDRESS 15E Hunns Lake Road: Apt ZIP 12581
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES l""l NO
13. A. AGE ?4 3B. DATE OF BIRTH 06 /64 A 983
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)
D. SOCIAL SECURITY NUMBER 091-68-3876
2 RESIDENCE A. NY 8. nlltr.he!=:!=:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Stanford
D STREET ADDRESS 15E Hunns Lake Road: Apt ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 24 3B. DATE OF BIRTH 03 / OF;
MONTH DAY
12581
YES ~ NO
/ 1 qR4
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION R('Ink Tpller
B. TYPE OF INDUSTRY OR BUSINESS Banking
5. PLACE OF BIRTH Sh;:lron CT
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A NAME Brien n \AlilkE'!r~Of"l
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME nehnr;:lh Ann Hohhs
B. COUNTRY OF BIRTH I J S A
8, NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES""-- . ,-..--
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Office Assistant
B. TYPE OF INDUSTRY OR BUSINESS Dc Social Services
15. PLACE OF BIRTH Pouahkeepsie NY
(CITY, Si'ATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME .Jar.nh Peter Sherman
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Pamela Ann White
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
o
o
DEATH
o
(2) 0 DEATH
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and
as to my right to enter into the
21. SIGNATURE OF GROOM ~
o
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
gal impediment exists
23. SUBSCRIBED AND SWORN TOI RMED BEF
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y rk State of the bride and groom named above by any person authorized
Relations Law 911 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
DATE
04/18/?008
by New York Domestic
~
{ SEAL }
"-v-'
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
AM
01 :38PM
2008
06
17 2008
04
19
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY );i)((~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF D(TOWN OF 0 VILLAGE OF
SPECIFY li)If..pP/~~
11>@ CIVIL
S
30. WITNESS TO ~EMONY /}
NAME (PRINl) )./t:JR'i.~~ !Zj/M:~ '-
SIGNATURE~ ~.AA./~ ~~
ZIP
".W"'"'~''' . .~
NAME(PRINl} ..' ~j/~~~A-
~1r.N"TIIRI=~ . ". ~ \. 0