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1.. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Th~~ Green ~!1im~~URNAME
I"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY nlltr.hA!=:!=:
CITYITOWN W::!ppingAr
~~J:f: 1 ~RR .
~~~I~~R ~7
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
R""bE'~~~EI ynn ~h1Mm~~URNAME
--1
11. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kinne\!
(OPTIONAL - SEE REVERSE) "]
D. SOCIALSECURITYNUMBER 4~7-~O-R125
12. RESIDENCE A. NY B. nl.tr.hA!=:!=:
(STATE) (COUNlY)
C. CHECK ONE 0 CITY Iii!' TOWN 0 VILLAGE
AND W '
SPECIFY ::!pplnger
D. STREET ADDRESS 37C Sherwood Forest ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES 1!1 NO
A ~ A~7R
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE) ,
D. SOCIAL SECURITY NUMBER ~?fi-R?-~~fi 1
2. RESIDENCE A. N~TATE) B. gM~ess
C. CHECK ONE 0 CITY WI TOWN 0 VILLAGE
AND W .
SPECIFY ::!pplngAr
D. STREET ADDRESS 37C Sherwood Forest ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES !!"t NO
3. A. AGE 29 3B. DATE OF BiRTH MO~ / DQ$ / vl.~78
4. EMPLOYMENT
A. USUAL OCCUPATION St.ldAnt
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Fv::!n!=:ton, lIIiniol';
(CITY, STATE I COuNTRY IF NOT USA)
6. FATHER
A. NAME r,IAnn Thorn::!!=: KinnAY
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Sheryl Lyn Green
B. COUNTRY OF BIRTH LJ S A
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
13. A. AGE 29
3B. DATE OF BIRTH
OR
MONTH
14. E~PLOYMENT
A. USUAL OCCUPATION ~h Irlent
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Sf Louis, Missouri
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME .J::!rne!=: AI::!n ~h::!ym::!n
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Deborah Berko
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?
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
...- YEAR
MONTH DAY YEAR
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) (CITYICOUNlY. STATE/COUNTRY, 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
to
20. IF PREVIOUSLY DIVORCED OR ANNULlLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNlY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT
/ /
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the
21. SIGNATURE OF GROOM.
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
nowledge and belief that the information I provided i
o 0
o 0
o 0
o 0
legal impediment exists
DATE
08/17/2007
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 08/17/200
Rd, Wappinger Falls, NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TY~ CEREMONY
TIME A YEAR 0 ~ELIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
TIME
YEAR MONTH DAY YEAR
MONTH
AM
03:04PM
08 18 2007 10 16 2007
29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED }
A. STATE NEW YORK B. COUNTYa{~
C. LOCATION 0 CEREMONY
(CHEC NE AND SPECIFY)
CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY /2 P(/'crf /7
NAME (PRINT)
SIGNATURE~
OOH-98 (0312006)