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1., A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Dani~LI~~rmgnd .Jeab~~ME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY nlltr.hA~~
CITYITOWN W;:!ppingAr
~~J:~~ 1 ~flR .
~~~~~R ~ 1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melis!tit&nn Hau~~~URNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 15?-66-~765 '
2. RESIDENCE A. N~TATE) B. ~eliilii
C. CHECK ONE 0 CITY oli1I TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 14F AlpinA nriVA ZIP 1 ?1190
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1lI NO
3. A. AGE 2Q 3B. DATE OF BIRTH ~ / ~~ / .;\i77
4. EMPLOYMENT
A. USUAL OCCUPATION Air Craft Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Tr;:!n~pnrt;:!tinn
5. PLACE OF BIRTH I nnn Rr;:!nr.h NAW IAr!'::AY
(CITY, S1'ATE I COUNTRy'IF NOT USA)
6. FATHER
A. NAME E\lermond Johnson
B. COUNTRY OF BIRTH II ~ A
7. MOTHER
A. MAIDEN NAME P;:!mAI::! Wnlf
B. COUNTRY OF BIRTH I I S A
B. NUMBER OF THIS MARF,lIAGE 1
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~S~(M~~~~~c~~sdohnion
D. SOCIALSECURITYNUMBER ?11~-71-11~0?
12. RESIDENCE A. NXSTATEl B. ~ss
C. CHECK ONE 0 CITY Iii! TOWN 0 VILLAGE
AND W '
SPECIFY ;:!pplnopr
D. STREET ADDRESS 14F AlpinA Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 24 3B. DATE OF BIRTH ~ ~~AY ..{~~
14. EMPLOYMENT
A.' USUAL OCCUPATION 1-I01lSA P;:!intAr
B. TYPE OF INDUSTRY OR BUSINESS Hnme Improvement
15. PLACE OF BIRTH RAil r.n1 mtv T AX;:!~
(CITY, STATE I coui'ffRY IF NOT USA)
16. FATHER
A. NAME Robert Francis Hal rrl'es.,Ar
'B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME ~heil::! I ynn Mr. Rh::!ne
B. COUNTRY OF BIRTHI J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIImES
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 CIVIL ANNULMENT
o 0
DEATH
o
DEATH
n
(2) 0 DEATH
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. STATEICOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. '.- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
.to.-IFPREVIOUSIXDIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CrTYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
YEAR
1ST
2ND
3RD
4TH
I duly swear/afflnn, deP.088
as to my righlto enter into
21. SIGNATURE OF GROOM ~
o 0 1~ 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
of my knowledge and beliel that the inlonnation I provided is true and that I declare that no legal impediment exists
_./'" ~
. ~SE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFO
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11to perfonn marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o II checked. this license is to be used only lor the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
08/10/2007
by New York Domestic
r-^-.
{ SEAL }
'-v-I
NAME (PRIm)
TIME
MONTH
YEAR
MONTH
YEAR
08/10/2007
ervFalls NY 12590
N STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
SIGNATURE ~
MAILING ADDRESS
20 Mi I
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. OFFICIA~ ~
NAME (PRIm)
09:02 AM 08
PM
10
09 2007
11
2007
28. PLACE WHERE MARRIAGE OCCU~
A. STATE NEW YORK B. cou~LI. rz,"'"
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /"
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY ~1;L6c;,,,,"
CIVIL
NAME (PRIm)
SIGNATURE~
DOH-9B (0312006)
NAME (PRIm)
SIGNATURE~