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COUNTY n I JtChFl!,;!,;
CITYfTOWN W::lppingFlr
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~~~~~~RR4
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
B' ~ tt '^'l:l'~
rIljU co I ~NT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dani~I!K~"'~rie Hn~~M~ SURNAME
1. A. FUll. NAME
11. A. FUll. NAME
FIRST
FIRST
..
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~JNi~~~~~C~~s~/hitten
D. SOCIAL SECURITY NUMBER 11 0-74-4356
12. RESIDENCEA.NY B.nlltr.hFl!,;~
(STATE) (COUNTY)
C. CHECK ONE D CITY D TOWNItJ VILLAGE
~~~CIFYW::lppingFlr!'; Falls
D. STREET ADDRESs14 Spring St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES D NO
A4 .fQRO
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIALSECURITYNUMBER 101-7?-1414'
2. RESIDENCE A. NY'" B. nlltrhess
(STATE) ~)
C. CHECK ONE D CITY D TOWNol] VILLAGE
~~~CIFY W::lrrinOAr~ F::lII~
D. STREET ADDRESS 14 Spring St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES D NO
3. A. AGE25 3B. DATE OF BIRTH M~ / tA~ / 1~~2
4. EMPLOYMENT
A. USUAL OCCUPATION ThrlIW::lY M~intAn::lnr.A WnrkAr
B. TYPE OF INDUSTRY OR BUSINESS NYST A
5. PLACEOFBIRTHPollnhk~F!p~ip., Np.w York
(CITY, ~ATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME I ::lrry Allp.n WhittAn
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dp.ni!';p. Marie Diesing
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
13. A. AGE?6
3B. DATE OF BIRTH
Oq
MONTH
14. EMPLOYMENT
A: USUAL OCCUPATIONR::lrtending
B. TYPE OF INDUSTRY OR BUSINESS Food And Beverage
15. PLACE OF BIRTHCold Soring New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMECarl Frederick Hooker
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Gail Mary Goodnow
B. COUNTRY OF BIRTtlJ S A
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) D DEAJH
(3) D ANNULMENT (2) D DEATH
/ /
. -- YEAR
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
-10;-IF-PREVIOUSLYDIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CrTYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
c. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CrTYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) D ANNULMENT
/ /
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and
as to my right to enter into
21, SIGNATURE OF GROOM~
D 0 1ST
D 0 2ND
D 0 3RD
D 0 4TH
owledge and belief that the information I provided is rue
D D
D D
D D
D D
at no legal impediment exists
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yo State of bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J n C. Masterson
{SEAL SIGNATURE ~. DATE 08/07/2007 TIME MONTH YEAR
'-v-' M~I~1OO~Fe appinger Falls, NY 12590 11 :44 AM 08 08 2007
STREET CrTYlTOWN STATE ZIP PM
~~~~~R~~~ 10~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ./
SONS NAMED ABOVE ON THE TIME Y YEAR 0 D RELIGIOUS 1 ~IVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 D OTHER, SPECIFY
08/07/2007
DATE
by New York Domestic
MONTH
YEAR
10
06 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou~Tt)f1ll&
C
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
D CITY OF 0 TOWN OF ~ILLAGE ~ J /
SPECIFY~f'r~ ~
SIGNATURE ~
MAILING ADD
y/
STREET
30. WITNESS 0
SIGNATURE~ ..
bOH-98 (0312006)
