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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~: 1368 '
~5~1~~~R 185
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bradle~ David Heatherl~
MID LE CURRENT S RNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Amv Elizabeth Paterson
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 428 13-1 081
D. SOCIAL SECURITY NUMBER -
2. RESIDENCEA. North Carolina B. Cumberland
(STATi) (COUNTY)
C. CHECK ONE fii"l CITY 0 TOWN 0 VILLAGE
~~~CIFY Fayetteville
D. STREET ADDRESS 113H Willow Run ZIP 28311
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED ViLLAGE? L1 YES 0 NO
3. A. AGE 29 3B. DATE OF BIRTH 06 / 20 / 1977
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Heatherlv
(OPTIONAL - SEE REVERSE) 115-68-0138
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY PouQhkeepsie
D. STREET ADDRESS 10 Merrimac Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS oFCITY OR INCORPORATED VILLAGE? 0 YES d NO
04 /03 /1983
MONTH DAY YEAR
13. A. AGE 23
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Army
B. TYPE OF INDUSTRY OR BUSINESS Government
5. PLACE OF BIRTH Tupelo. Mississippi
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Mt. St. Mary College
15. PLACE OF BIRTH Poughkeepsie. New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME John Ferqus Paterson
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Patricia Ann Coy
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
6. FATHER
A. NAME Terry Akers
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Julia Tutor
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) d'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03/ 21 / 2006 c. DATE LAST MARRIAGE ENDED?/ /
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 0 NO O. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) ICITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
03/21/2006 Fayetteville, North Carolina 0 d 1ST 0 0
o 0 ~D 0 0
o 0 ~D 0 0
o D 4TH D 0
t to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
e. t1.<c~ IA~ '/
OF BRIDE~ !L:Zr: ~~
USE CURRENT NAME
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say
as to my right to enter into the m ,
21. SIGNATURE OF GROOM
12/18/2006
w
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Z
W
o
::i
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in NeW York State of th
Relations Law ~11 to perform marriage ceremonies within New York
D If checked, this license is to be used
~ 24. TOWN OR CITY CLERK
} NAME (PRINT) John C. Masterson
{SEAL SIGNATURE" DATE 12/18/200
'-- -.J MAllJNG ~i:PIR,E~~eb
-v- LU IVIIOOU appinger Falls, NY 12590
STREET CITYrrOWN STATE ZIP
~~~R~~RT~~ lo~O~~~N~zf~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 D RELIGIOUS 1'$'CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 'Dc.rrc HesS
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY '?a u G H "f::cP.I1 t::
DATE
by New York Domestic
bride and groom named above by any person authorized
te. THIS LICENSE VALID IN NEW YORK STATE ONLY.
nly for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
YEAR
MONTH
YEAR
TIME
MONTH
AM
01 :36pM
12
19
2006
02
16 2007
.fIN'
NAME (PRIND
SIGNATURE"