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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nathaniel Wilford Marion
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~J~~; 1368 '
~5~~~~R 51
1. A. FULL NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 153 84 8792
D. SOCIAl SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUN1Y)
C. CHECK ONE 0 CITY tl TOWN 0 VILLAGE
~~~CIFY Wappinoer
D. STREET ADDRESS 8B Carnaby Street ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 26 3B. DATE OF BiRTH 05 / 19 / 1981
MONTH DAY YEAR
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nadine Marie Ellison
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ellison-Marion
(OPTIONAL - SEE REVERSE) 072-68-4075
D. SOCIAl SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r!f TOWN 0 VILLAGE
~~~CIFY Wappinoer
D. STREET ADDRESS 8B Carnaby Street ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
12 /18 /1'980
YEAR
13. A. AGE 26
3B. DATE OF BIRTH
MONTH
IDAY
...
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4. EMPLOYMENT
A. USUAL OCCUPATION Sales Enoineer
B. TYPE OF INDUSTRY OR BUSINESS Timco Incorporated
5. PLACE OF BIRTH Plainfield, New Jersey
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Wayne Wilford Marion
B. COUNTRY OF BIRTH USA
14. EMPLOYMENT
A. USUAL OCCUPATION Industrial Hygienist
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
15. PLACE OF BIRTH Plattsburgh, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Edward Ellison
'B. COUNTRY OF ~I~TH U S A
17. MOTHER
A. MAIDEN NAME Fortune Elizabeth Pellicano
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
D~TH
7. MOTHER
A. MAIDEN NAME Linda Margaret Schneider
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. ~~~~~~iRM6'f~~~~us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
B. HOW 010 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, dep'ose and say, that to the best of my knowledge and belief that the information I provided Is true a d t at I
as to my right to enter into the mam e s te. . ~
21. SIGNATURE OF GROOM. NATURE OF BRIDE.
o 0
o 0
o 0
o 0
a imP4$!!.ment exists
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage In New York State of authorized
Relations Law ~11 to perform marriage ceremonies within New Yo tate. 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 ceremon .
,-I'-.. 24. TOWN OR CrT'( C ERK M t 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JO . as e son
{SEAL SIGNATURE ~ . DATE 06/15/2007 TIME MONTH YEAR
'- -.J MAI~ MMt:ll~b ppinger Falls, NY 12590 AM 06 16 2007
--v- 03:03pM
STREET CITYITOWN STATE ZIP
~~R~~RT:~ 10~O~~N:.zEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY Y AR 0 ~GIOUS
DATE AND AT THE TIME AND :-....
PLACE INDICATED. vv PM 9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 t03l2006\
MONTH
YEAR
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
08
14 2007
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) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY c1h~1L-
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ OF 0 VILLAGE OF
SPECIFY O!:u
.
/~? ~
ZIP
"::=rocU~Q,t ;?'~(.\~.
SIGNATURE~ ~ =.,-~