108
+
w
LOli:
01;;
o
CO
<0
W I-
ffiz :;
~ Q) ~
c:::::J _
:5 >w &L
~ Q)~ &L
Ul Q)~ CC
~lD
>=
~g
~ ~
a <.l
w
a:
w
<!I
<
ii:
a:
~.
u.
o
.~
o
u:
~
w
o
w
a:
w
i
Ul
Ul
w
a:
c
c
<
~
u
w
n-
Ul
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
G al \/ 1M ~
reQQfi' an e~ Q SURNAME
COUNTY nlltche!';!';
CITYfTOWN Wappinger
~~J:~C: 136R '
~5~~J~R 10R
1. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER ?64.-37 -4.fi70
2. RESIDENCE A. N~ATE) B. 9~6~
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND
SPECIFY RAIIAVIIA
D. STREET ADDRESS 2fi07 Madison Street ZIP 68005
E. IS RESIDENCE WITHIN UMITS OF CITY DR INCORPDRAlED VILLAGE? ~ YES 0 NO
3. A. AGE 44 3B. DATE OF BiRTH Mc!JJ /,~ / ~R63
4. EMPLOYMENT
A. USUAL OCCUPATION Milit::lry
B. TYPE OF INDUSTRY OR BUSINESS U S Navy
5. PLACE OF BIRTH 8nmswick, Maine
'(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME .IArnmA FrArlrir.k VArlinrlA
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gwendolyn Carol Hicks
B. COUNTRY OF BIRTH USA
B, NUMBER OF THIS MARF,UAGE 2
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
9. ~~~~~~~R~r~/(E<vr8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID lAST MARRIAGE END? (3) I!l'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 06/ 21 / 2007
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 AGAINSTWHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
06/21/2007 Kansas City. Kansas rt
1ST
2ND
3RD
4TH
I duly swear/affinn, dep.ose and say, that
as to my right to enter into the mama
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Eli7~D~lEh Ann Mr'c&~I~T SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SVS~~~~~~~~~~~~S~ E'rllindE'
D. SOCIAL SECURITY NUMBER 088-60-5865
12. RESIDENCE A. N fsTATE) B. ~7cfI]~)
C. CHECK ONE oIZJ CITY 0 TOWN 0 VILLAGE
~~CIFY BellevlJe
D. STREET ADDRESs2507 Madison Street ZIP 68005
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORAlED VILLAGE? ~ YES 0 NO
,,03 ;(q69
DAY YEAR
13. A. AGE 38
14. EMPLOYMENT
A. . USUAL OCCUPATION Policy Analyst
B. TYPE OF INDUSTRY OR BUSINESS S. A. I. C.
15. PLACE OF BIRTH Manhattan. New York
(CITY, STATE I COUNTRY IF NOT USA)
3B. DATE OF BIRTH
03
MONTH
16. FATHER
A. NAME John Mc Fall
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Elizabeth King
B. COUNTRY OF BIRTHlreland
1B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID lAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05 / 20 / 1997
MONTH DAY.' - - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? i!f YES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
OS/20/1997 PouQhkeepsie, Ny ~
DEATH
o
1ST
2ND
3RD
4TH
that the infonnation I provided is tru
rr.'
w
~
:>
z
Q
Z
<
Iii
w
~
23. SUBSCRIBED AND SWORN TO/AFFIRMED B
SIGNATURE OF TOWN OR CITY CLERK" DATE
This license authorizes the marriage in New York State of he bride and groom named above by any person authorized by New York Domestic
W Relations Law ~11 to perfonn marriage ceremonies within New Yo tate. 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) Joh .
o { TIME MONTH DAY YEAR MONTH
::::i SEAL SIGNATURE" ;
~ MA~~~fcT8fS Rd, Wa 08:33AM 09 01 2007 10 30 2007
STREET PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
+
~~z
~~S
rr."~
~~~
:>ow
::;<!Ic5
!z~Ul
~~~
ltou>
0....>-
..w~
~~lt)
o~z
Z:J_
o
o
YEAR
1~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cotf41t~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)