141
+
t-
ffi :>
~ c(
9 c
=>. w u:
~ ~ ~
Z ;;
o. ~
~ ~
l;; t:
C!i 0
W
II:
W
o
<
a: .
II:
:i
...
o
..t!!.
<
o
u:
~
w
o
W
II:
W
~
l!l
w
II:
o
o
<
~
(3
w
"-
en
11:'
W
III
:::!!
=>
Z
o
ll:
Ii;
W
II:
>-
Ul
w
en
z
w
(,)
::::i
+
~:i::i W
=>t::Q
~;:~ t-
a:~_ c(
>-wZ
en...:::!! (,)
=>ow
:::l!oc5 u:
!z~en ~
~~~ It:
ttoU) w
0>-> (,)
..w~
~ffiU)
~g~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST AlexaEJ6!~r Dennis &?iRNAME
COUNTY [)lIkhp.!';!';
CITYfTOWN W~rringp.r
~~J~~C: 1 ~nR '
~5~1:~~R 141
1. A, FULL NAME
"-
N
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) ,
0, SDCIALSECURITYNUMBER 052-62-4135
2, RESIDENCE A, N);'TATE) B, Q~ess
c, CHECK ONE 0 CITY oItI TOWN 0 VILLAGE
AND
SPECIFY Lagrange
0, STREET ADDRESS 1?A. 1\A::Ir.Ohp.p. Rrl ZIP 1 ?nn~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES III NO
3. A AGE 30 3B, DATE OF BiRTH on / ')1; /y1077
MOIml' tmY" ~
4. EMPLOYMENT
A, USUAL OCCUPATION Merchandil!ie Handler
B, TYPE OF INDUSTRY OR BUSINESS Retail
5. PLACE OF BIRTH fc~~~~~o~~J~ ~o~x.)
6. FATHER
A. NAME Charles Parde9
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Georgette Edwards
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
'-DIVORCE-'-.----cIVlL-ANNtJI:MENT.-.-..
w
~
. DEATH
o
o
(2) 0 DEATH
o
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jes~bb~ Lee Har~fNTSURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. sy8~t~M~~~t~~~~~sF,ardee
D. SOCIAL SECURITY NUMBER m:JO-R?-QfifiA.
12. RESIDENCE A. N'(STATE) B. ~ss
C.CHECKONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFY W~ppinoer
D. STREET ADDRESS 17 ~11r.ir.h PI~cp. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Ii!'l NO
13. A. AGE 28 3B. DATE OF BIRTH QO"m-H /-i ~AY -1 ~Z~
14. EMPLOYMENT
A. USUAL OCCUPATION Sales Man~!Jer
B. TYPE OF INDUSTRY OR BUSINESS Rp.t::lil
15. PLACE OF BIRTH YnnkAr~ NY
(CITY, STATE I doUNTRY IF NOT USA)
16. FATHER
A. NAME Richard warren Harmer
'B. COUNTRY OF BIRTH I J ~ A
17. MOTHER
A. MAIDEN NAME K::Irp.n I ynn P::Ilmp.r
B. COUNTRY OF BIRTH II ~ 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
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
MONTH DAY
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) (CITYIOOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,-- YEAR
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of 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 state. ' ~
21. SIGNATURE OF GROOM~' /J 22. SIGNATURE OF BRIDE~ ~f1JUI ioe-
US USE CURRE NAME
23. ~::~~~~DC:%~~OJl: ci~A~r:r:E~ BEFORE M DATE 11/07/2007
This license authorizes the marriage in New rk State the bride and groom named above by any person authorized by New York Domestic
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 onl for the pu se of a second or SUbsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
,-A-..
{ SEAL }
'-v-I
NAME (PRINT)
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME MONTH YEAR MONTH YEAR
AM 11 08 2007 01 06 2008
06:28PM
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL STATE NEW YORK B. COUNTY O(.L-\che~)
A.
STATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY'~G~r~~~~ ~\l\
ZIP
"wrrN<$roCj' it.-
NAME (PRINT) "tV\. r.e ?
SIGNATURE. 7+--