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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ri~h~~ r,~mA Ri~~'JJ<JURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~~: 1368 '
~5~1:~~R 136
1 . ~. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT.
C. SURNAME AFTER MARRIAGE
D. ~~<;~~~E~U~~~~RSE) 083-42-5496
2. RESIDENCE A. NY B. III~tAr
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND h
SPECIFY M;:!rlhoroug
D. STREET ADDRESS 61 Sands Ave. ZIP 12547
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 57 3B. DATE OF BIRTH n~ / n!l / 1 Q!ln
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Trll~k [)rivAr
B. TYPE OF INDUSTRY OR BUSINESS Sanitation
5. PLACE OF BIRTH (slip, New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME HArm;:!n Ringgold
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dorothy E. Smith
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
...... -A.-NUMB6R-Qp-PRe.vIQIJS-MAElRlAGES-W~ENDED..BY. .. .
DIVORCE CIVIL ANNULMENT
o 0
DEATH
1
(2) crDEATH
1999
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 04/ 02 /
MONTH .9AY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES cYNO
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 ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A. FULLNAME FIRST E~~xn Manni~RRENTSURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT ~AymorA
C. SURNAME AFTER MARRIAGE Ringgold
(OPTIONAL. SEE REVERSE) 101 42 6328
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEA. NY B, Ulster
(STATE) (COUNTY)
C, CHECK ONE 0 CITY !tl' TOWN 0 VILLAGE
~~~CIFY Marlborough
0, STREET ADDRESS 61 Sands Ave.
ZIP 12547
DYES~NO
A950
YEAR
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A. AGE !l7 3B. DATE OF BIRTH 02 .Al9
MONTH DAY
14, EMPLOYMENT
A. USUAL OCCUPATION Reception
B. TYPE OF INDUSTRY OR BUSINESS Health Care Services
15. PLACE OF BIRTH Bellport. NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Unknown
'B. COUNTRY OF BIRTH Unknown
17. MOTHER
A. MAIDEN NAME Unknown
B. COUNTRY OF BIRTH Unknown
1B. NUMBER OF THIS MARRIAGE 3
o
o
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
'DIVORCEU" CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3) d'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 12 / 2000
MONTl1.J DAY' ". - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [J YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLlED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 08/12/2000 Nassau County, New d 0
2ND 09/11/1989 Suffolk County, New York ~
3RD
DEATH
o
1ST
2ND
3RD
4TH
I duly swear/affirm, dep'0S8 and s
as to my right to enter into the
21. SIGNATURE OF GROOM. '"
NAME (PRINl)
~\
USE CU
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in NewYor State of the bride and groom named above by any person authorized by New York Domestic
W Relations Law ~11to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
en 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z ~ 24. TOWN OR CITY CLERK 25. A, SOLEMNIZATION PERIOD BEGINS
W } NAME (PRINT) Jo C. Maste on
o { C TIME MONTH YEAR MONTH
:::::i SEAL SIGNATURE ~. DATE 10/10/200
'-v-I MAI~ ~?B~e sh Rd, ppingers Falls, NY 12590 04:28:~ 10 11 2007 12 09 2007
STREET ClTYrrOWN STATE ZIP
~~R~:RT.:~ lo~O~~Nif:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 .~ELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 3: ~ 9 0 OTHER, SPECIFY
~~3lf~~~ -R'f..\Jerl'tJ d ~.('') _ LhfuXD..\\~ 'III TITLE PA~\:o("
SIGNATURE~ fDi.! $/\ DcY'l'.i.L1f DATE~
MAILING ADDRESS
~ t1'ld~lt. ~&)A>Jd ~,l i Nu\wd J tJCw Yorl 11'1 b ~
STREET CITYrrOWN' I STATE
o Y It
SIGNATURE~
nnL.l_QA In~l?nnR\
o
o 0
o 0
declare that no legal impediment exists
{'
22. SIGNATURE OF BRIDE.
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF I2"1'bWN OF 0 VILLAGE OF
SPECIFY JjeJ ~I' A
SIGNATURE~