099
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swe!lr/affirm, depose Bnd say, that. to the 7:3,est my owledge and belief that the information I provided. is t
as to my right to enter Into the mar estate. .
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21. SIGNATURE OF GROOM~ . IGNATURE BRIDE~
USE CURRE NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New .York State of the b e and groom named above by any person authorized by New York Domestic
W Relations Law ~11 to perform marriage ceremonies within New York State. IS LICENSE VALID IN NEW YORK STATE ONLY.
UJ 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z r-I'-. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W { } NAME (PRINT) Jo C. Mas erson
(.) TIME MONTH YEAR MONTH
:J SEAL SIGNATURE ~ DATE 08/23/200
"-- -..J MAII,l~ ~QOI'f\E~:>eb
-yo- LU Mlaall appingers Falls, NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 0 RELIGIOUS
9 0 OTHER, SPECIFY
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brli~EThom&i ~~lirSURNAME
COUNTY nlltr.hA~~
CITYfTOWN W::JrringAr
~~~:~ 1 ~RR .
~5~1:;~R ~~
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIALSECURITYNUMBER OR?-7?-~71~'
2. RESIDENCE A. N;(TATE) B. QM~ess
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND P hk .
SPECIFY nllQ AAr!'::IA
D. STREET ADDRESS ?~ Anthony nrive Apt D20:lzlP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 26 3B. DATE OF BIRTH M~~ / D1? / yl~81
4. EMPLOYMENT
A. USUAL OCCUPATION Coati'lQ T Ar.tmici::m
B. TYPE OF INDUSTRY OR BUSINESS Smith's nAtedion
5. PLACE OF BIRTH Rronx NAW York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME ArQel I Ollis P.\Iil::l
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME K::JthlAAn Ann I IIro
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. 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?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
YEAR
MONTH DAY
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 STA TE USE ONL Y)
~
Lo
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11. A. FULL NAME
SUPPLEMENTAL FILE
FROM THE BRIDE
1<E'IIYM~rr F\t1(' SP~~~~SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Lh/ila
(OPTIONAL. SEE REVERS")
D. SOCIAL SECURITY NUMBER 118-64-7163
12. RESIDENCE A. NY B. [1llt('hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY Iil TOWN 0 VILLAGE
AND P hk .
SPECIFY Ollg AApSle
D. STREET ADDRESS 25 Anthony Drive Apt. D201 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!l NO
13. A. AGE 27 3B. DATE OF BIRTH O~ A 4 A ~RO
MONTH DAY YEAR
14. EMPLOYMENT
A.' USUAL OCCUPATION r.11~tomAr SArvie:A Rep
B. TYPE OF INDUSTRY OR BUSINESS Liberty Mutual
15. PLACE OF BIRTH Cold Sprina. New York
(CITY. STATE I couN'i"Ry IF NOT USA)
16. FATHER
A. NAME ~A()rgA K Me: SrFlnon
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Ellen Louise White
B. COUNTRY OF BIRTH USA
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?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
...- YEAR
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
YEAR
08
24
2007
10
22 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou;;;;{!c....Tc.I/tIJB
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
PECIFY EI'J.I!" -r F1 s J.k:t- LL.
NAME (PRINT)
SIGNATURE~