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1. A. FUll. NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Thomff John T~R~ij.SURNAME
I"
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
COUNTY nllkhp.!=:!=:
CITYfTOWN W~rringp.r
~~~:f; 1 ~nR .
~~~~~R 1 ?~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Shar'\.,~DR~ Phylli~ Fct\fJ~TSURNAME
11. A. FUll. NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) ,
D. SOCIAL SECURITY NUMBER 1 nA.-~A.-~ q 1 A.
2. RESIDENCE A. N'(STATE) B. qMh~ess
C. CHECK ONE 0 CITY.,I[J TOWN 0 VILLAGE
AND \AI '
SPECIFY vv~pr'"ger
D. STREET ADDRESS 9? O~hnrnA Hill Roan; Apt ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESIIt\ NO
3. A. AGE35 3B. DATE OF BIRTH M~ / ~ /1872
4. EMPLOYMENT
A. USUAL OCCUPATION Social '^'orkE'r
B. TYPE OF INDUSTRY OR BUSINESS r.PS
5. PLACE OF BIRTH Pnllnhkp.p.n!=:ip:, Nv
(CITY. afATE I COiJNTRY IF NOT USA)
6. FATHER
A. NAME Thomas lohn Tail. Ir
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME I inrl~ I P.P. r.r~mp.r
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARijlAGE 2
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE T ait
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ?7 -70-7278
12. RESIDENCE A.NY B.nlltr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applngAr
D. STREET ADDRESs92 Osborne Hill Road: Apt
ZIP 12590
o YES"l"J NO
;(q7?
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE?
13. A. AGE34 3B. DATE OF BIRTH 1? /1'1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Snr.i~1 WorkAr
B. TYPE OF INDUSTRY OR BUSINESS CPS
15. PLACE OF BIRTHSoutham~ton
(CITY. STATE I C UNTRY IF NOT USA)
16. FATHER
A. NAMERnhp.rt F~rly
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Lynda Ann Morton
B. COUNTRY OF BIRTJJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE'~'~-CIVlb"NNUl:MENT' DEATH
1 n n
B. HOW DID LAST MARRIAGE END? (3) !!1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? nq / ?3 / ?OO?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
1ST 09/23/2002 Poughkeepsie, Ny ~ 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that 0 the be of my knowledge and belief that the Information I provided is true an
as to my right to enter into the mam te.
21. SIGNATURE OF GROOM~
U C
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New 'l rk Slate of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York Slate. 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
C. Master on
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
'".- YEAR
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) (CITYICOUNTY. STATElCOUNTRY. IF NOT USA) SELF SPOUSE
o
D
o
22. SIGNATURE OF BRID
by New York Domestic
r-^-.
{ } NAME (PRINT)
SEAL SIGNATURE ~
MAILING ADDRESS
'-v-I 20 Middl
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT D
NAME (PRINT) e::e
MONTH
YEAR
YEAR
TIME
MONTH
DATE 09/19/2007
ppinaers Falls. NY 12590
CITYiT'OWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME M. DAY YEAR 0 Iiil'1lELIGIOUS
/ : vz :- ~ 9 0 7 9 0 OTHER. SPECIFY
...J. W hlEt2 t- TITLE
AM
05:03 PM 09
20
2007
11
18 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~OWN OF 0 VILLAGE OF
SPECIFY iJ,~ !lc.f::.
10 CIVIL