021
+
I-
Z
w
m
w
III
C
...J
::>
o
::t
m
z
o
~
~
(;
w
a::
w
~
a:
a::
~
u.
o
w
!;(
(.)
ii:
~
w
(.)
w
a::
w
~
m
m
w
a::
c
c
<
it
u
w
"-
m
w
(/)
z
w
o
-:J
+
~~z
2~g W
~,,~ to-
~~~ 0<
::>(.)W
:l:(!l5 i!
tz~m -
~~15 ~
item w
~~~ 0
~ffi~
~g~
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christooher Earl Blackman
FIRST MIOoLE ' CURRENT SURNAME
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c: 1368 .
~~~I:;~R 21
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Joantue Cintron
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Blackman
(OPTIONAL - SEE REVERSE) 046 72 0507 (OPTIONAL - SEE REVERSE) 080-64-0916
D. SOCIAL SECURITY NUMBER - - D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess 12. RESIDENCE A, New York B. Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VilLAGE C. CHECK ONE D CITY r!t TOWN D VILLAGE
~~~CIFY Waooinaer ~~~CIFY WappinQer
D. STREET ADDRESS 6 GranQer Place ZIP 12590 D. STREET ADDRESS 6 Granger Place ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES 1!1' NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ j NO
3. A. AGE 26 3B. DATE OF BIRTH 11 / 06 / 1980 13. A. AGE 26 3B. DATE OF BIRTH 05 /24 /1980
MONTH DAY YEAR MONTH DAY YEAfl
4. EMPLOYMENT
A. USUAL OCCUPATION Information Technology Mgr.
B. TYPE OF INDUSTRY OR BUSINESS Empire State BuildinQ
5. PLACE OF BIRTH Danburv. Connecticut
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Edward E. Blackman
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Suzanne Southard
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Administrator Assistant
B. TYPE OF INDUSTRY OR BUSINESS Community Ser. Prog.
15. PLACE OF BIRTH Manhattan, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Emilio Cintron. Jr.
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Paulette Denise Lewis
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
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) (CITYICOUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(2) D DEATH
(3) D ANNULMENT (2) D 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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose a
as to my right to enter into
21. SIGNATURE OF GROOM ~
D
D
D
D D
D D
D D
D D
at no legal impediment exists
1ST
2ND
3RD
4TH
that the information I provided is tru
USE CURRE N E
23. SUBSCRIBED AND SWORN TOIA IRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the ride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York Stat. 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) Jo C. Masterson
{ ~ ~ ~
SEAL SIGNATURE ~ DATE 03/27/200
'-- ~ MAII,.ING .QDI'FlE$,Se 09:32AM 0
-v- LU MIOalE appinger Falls, NY 12590 PM 03 28 2 07
STREET CITYITOWN STATE ZIP
~~~R~~RT~~J IO~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o)c RELIGIOUS
DATE AND AT THE TIME AND ,_ AM
PLACE INDICATED. lU lID P () If I> to 0 9 D OTHER, SPECIFY
~~Str~~mT t<eVI RAt..{J1-I v: IJ-h1t1AJD$fZ/lI TITLEJn-fUb)f1, J1't(~iSTe.t<
SIGNATURE ~ '" ~ J "l\ oll 'i', A- ~ DATE 1Ifl1lt~ ~. d-tJO 1
MAILING ADDRESS · IJd II --r ch
.;;2.3 IL'-J..~e vie (J)I\ ff't!)Jewell J(/J1 'ON, /Vl/ ! 2~ ~ '5
STREET '1 , CITYfffi~1N I ST~TE
DATE 03/27/2007
by New York Domestic
MONTH
YEAR
05
26 2007
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couNTYJ>lJh:.l1ess
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~ TOWN OF D VILLAGE OF
~LitPP( NGOC
~
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
=----