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105 + w !< ~t; l.O N ..- >- ~ ffiz :; ~c ~ ,,0 _ -'Uwu. ~m~U. ~ CO rea: ~..-g t;.....~ ffi<(o II: w.... !iQ) 1i:~ II:..... ~cn 15en en ~o fft; j:: ~""" W II: W ~ en en w II: " " <( ~ i3 w l1. en rr.' w III :::E :> z c z <( Iii w ~ w -0 z w (.) :::i + ~~~ W ?~j:: ~,,;:j ~ ~~~ C(.) :>ow ~Cl5 i:L !Zi!!:tIl - ~~15 t: tEeen W ~~ ~ (.) I!!~U) ~~i!!: STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM Fr;:!nklin LemeLJI Thomnson MIDDLE CURRENT SURNAME B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE)067 58 7839 D. SOCIAL SECURITY NUMBER __ - _ - 2. RESIDENCE A. NY B. Dutchess (STATE) (COUNTY) C. CHECK ONE ~ CITY 0 TOWN 0 VilLAGE ~~~CIFY Beacon D. STREET ADDRESS 4 Cross Street: Apt 1 ZIP 12508 E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~ YES 0 NO 3. A. AGE 31 3B. DATE OF BiRTH 11 / 09 /1975 MONTH DAY YEAR COUNTY Dutchess CITYrrOWN Wappinger ~~;:~c: 1368 . ~~~~~~R 1 05 1. A. FULL NAME FIRST l1. N 4. EMPLOYMENT A. USUAL OCCUPATION Carpenter B. TYPE OF INDUSTRY OR BUSINESS Carpentry 5. PLACE OF BIRTH Beacon. NY (CITY, STATE I COUNTRY IF NOT USA) 6. FATHER A. NAME Franklin Thompson B. COUNTRY OF BIRTH USA 7. MOTHER A. MAIDEN NAME Ramona Joyce Oliver B. COUNTRY OF BIRTH USA 8. NUMBER OF THIS MARRIAGE 1 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE ........___"....C~Vll_ANNULMENT. o 0 B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / I STATE FILE NUMBER (THIS SPACE FOR STATE USE ONL Y) I L 0 SUPPLEMENTAL FILE FROM THE BRIDE Don~~~a Marie Br~'<<~NT SURNAME -.J 11. A. FULL NAME FIRST B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT C. SURNAME AFTER MARRIAGE Thompson (OPTIONAL - SEE REVERSE)134 72 2052 D. SOCIAL SECURITY NUMBER -- 12. RESIDENCE A. NY BD utch ess (STAT.E> (COUNTY) C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE ~~~CIFY Beacon D. STREET ADDRESs4 Cross Street; Apt 1 ZIP 12508 '6 E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 13. A. AGE 28 3B. DATE OF BIRTH 05 ,.(11 MONTH DAY YES 0 NO ;1'979 YEAR 14. EMPLOYMENT A.' USUAL OCCUPATION Medical Coder B. TYPE OF INDUSTRY OR BUSINESS Medical 15. PLACE OF BIRTH Cold SprinQ, NY (CITY, STATE I COUNTRY IF NOT USA) 16. FATHER A. NAME Charles Atkins 'B. COUNTRY OF BIRTHU S A 17. MOTHER A. MAIDEN NAME Shiela Brown B. COUNTRY OF BIRTHU S A 18. NUMBER OF THIS MARRIAGE 1 DEATH o 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DEATH o (2) 0 DEATH (3) 0 ANNULMENT (2) 0 DEATH / / ,..- YEAR MONTH DAY YEAR D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO 1D. 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 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 1ST 0 0 1ST 2ND 0 0 2ND 3RD 0 0 3RD ~ 0 0 ~ I duly swear/affirm, depoSB and say, that to the best of my knowledge and belief that the information I provided is t as to my right to enter into the mama estate. . ,/ 21. SIGNATURE OF GROOM ~ o 0 o D o 0 o 0 legal impediment exists 22. SIGNATURE OF BRIDE USE CU E 23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME SIGNATURE OF TOWN OR CITY CLERK ~ This license authorizes the marriage in New Yo State of th bride and groom named above by any person authorized Relations Law ~11 to perform marriage ceremonies wit In New York State. 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. r-I'-. 24. TOWN OR C'1 ERK 25. A. SOLEMNIZATION PERIOD BEGINS { } NAME (PRINT) 08/29/2007 TIME MONTH YEAR SEAL SIGNATURE ~ DATE '-v-' MA~(f1OO'Cfm appingers Falls, NY 12590 06:48 ~~ 08 30 2007 STREET CITYITOWN STATE ZIP I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY THE MARRIAGE OF THE PER- SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1ft CIVIL ~t:6E ~~g,C~~~E TIME AND 2 : 55 AM 09 15 07 9 0 OTHER, SPECIFY 29. OFFICIANT NAME (PRINT) by New York Domestic MONTH YEAR 10 28 2007 28. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. couNTYDUTCHESS TITLE MARRIAGE OFFICER DMESEPTEMBER 15. 2007 C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF Xl TOWN OF 0 VILLAGE OF POUGHKEEPSIE SPECIFY