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COUNTY Dlltr.hp.!,:!,:
CITYrrOWN W;:)ppingp.r
~~~:f: 136R '
~~~I;~~R 1 A.A.
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Edml;&fa~EJerm3inEl:~ttRNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
AlaisaM'M~oria CarQ~7'<;URNAME
1 , A, FULL NAME
1 L A, FULL NAME
FIRST
FIRST
11.
N
B- BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c, S~S~J~~~~~t~~C~~S~3rdenez Scott
D, SOCIAL SECURITY NUMBER 1 08-60-4 ?q6
12, RESIDENCEA.NY(STATE) B.D~~ss
C. CHECK ONE 0 CITY olil TOWN 0 VILLAGE
~~~CIFYWappinger
D. STREET ADDRESs1 A. 7 All Angp.l!': Hill Rn;:)rl ZIP 1 ?fl90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ol'J NO
13. A. AGE30 3B. DATE OF BIRTH ~NTH 1~AY {~1~
14. EMPLOYMENT
A. USUAL OCCUPATION CiiiU;e Mlimager
B. TYPE OF INDUSTRY OR BUSINESS Ment;:)1 He;:)lth
15. PLACE OF BIRTH Manhattal'l NeVil Vorl<
(CITY. STATE / COUI'rrRY IF NOT USA)
16. FATHER .
A. NAME john Card9m~z
'B. COUNTRY OF BIRTft-lOl'ldl ,ras
17, MOTHER
A. MAIDEN NAME \lernE'1I1 orrail'lp. Cr~wfnrrl
B, COUNTRY OF BIRTt-i I S fi.
1B. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B, BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) ,
D. SOCIAL SECURITY NUMBER 061-68-7889
2. RESIDENCE A, N'(STATE) B. qMt~es8
c, CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
~~~CIFY Wappinger
D, STREET ADDRESS 147 All Angel., Hill Rn~rl ZIP 1 ?!1QO
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES olJ NO
3. A. AGE 27 3B. DATE OF BiRTH MOW / ~6 / 1j~0
4, EMPLOYMENT
A. USUAL OCCUPATION Youth CQunselor
B. TYPE OF INDUSTRY OR BUSINESS Goldsmith Center .
5. PLACE OF BIRTH1c9~~/sQA~fc~S.t1\rNgffillA)Ne\A1 York
6. FATHER
A. NAME Wayne Scott
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Valerie Sessions
B. COUNTRY OF BIRTH I I S A
B. NUMBER OF THIS MAR81AGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE.. .CIVILANNULMENT
DEATH
DEATH
o
o
o
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
MONTH DAY
0, 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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.' - YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, depose and sa~y. that to f my knowledge and 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 ma ge st ---.
C- C--
21. SIGNATURE OF GROOM~ NATURE OF BRIDE~ ~ -
USE USE CURRENT NAME ~
23, ~~rf~~~Do~N.fo~;~Oo~ ci~A~r:r::~ BEFORE ME DATE 11/1 fi/?007
This license authorizes the marriage in New York State of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York tate. 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 }
'-v-I
YEAR
MONTH
YEAR
TIME
MONTH
AM
02:48 PM 11
17
2007
01
15 2008
STATE
27, TYPE OF CEREMONY
o .J~" RELIGIOUS
9 0 OTHER, SPECIFY
CITY
26. SOLEMNIZATION OCCURRED
STREET
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 V e 5+<..J-.n+//
c, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY Tee~:s A ; 1/
10 CIVIL
TIME MO. DAY YEAR
lj"OG AM /2- I'-{ 07
~.\':::.= t/J. G~"'-t1" tL-
~~~~W~5~~~ ft;r
7... 4 q $'. I J rL.,4-...:- t11t' VCrnfq..v
STREET CITYrrOWN
3D. WITNESS TO CERE ,o~~ 11../ .P / J 1-. ~ /? 4 w -fe-r d
NAME (PRINT) '"V"...... V/ C
TITLE
It)''} f. P Af+ot..
11-/N/01
(O)lu
ZIP
EREMONY
DATE
f-'[TATE
NAME (PRINT)
SIGNATURE~
SIGNATURE~
DOH-9B (0312006)