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COu~utchess
CITYfTOWNWappinger
~~~:~R'" 368
~~~1~~~R183
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin Ellesworth Falconer
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Velvee Lee King - Harvey
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
11.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Falconer
(OPTIONAL' SEE REVERSE~ 10-52-8086
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY"6 TOWN 0 VilLAGE
D. ::~;::~~~A~mlet Court
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEh62_48_9865
D. SOCIAL SECURITY NUMBER U
2. RESIDENCE ANew York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 ClrMJ TOWN 0 VilLAGE
~~CIFY Wappinqer
D. STREET ADDREss45 Hamlet Court ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES''''''o NO
A. AGE51 3B. DATE OF BIRTH 04 /21 /1955
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGc48 3B. DATE OF BIRTH 07 /14
MONTH DAY
ZIp12590
o YES....O NO
)958
YEAR
EMPLOYMENT .
A. USUAL OCCUPATION Truck Driver
B.TYPE OFINOUSTRYOR BUSINess Duso Chemicals
5. PLACE OF BIRTHSrooklyn, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME William Compton
B. COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME . Merle Falconer
B. COUNTRY OF BIRTH USA
8. 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. USUALOCCUPATIONNurse
B. TYPE OF INDUSTRY OR BUSINESSA& A Staffing
15.'PLACE QFBIRT).l1artinsville..\!irginia~.
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEWalter Clarence King
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Mary Lois Smith
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 3
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT D;,ATH
2 O' U
B. HOW DID LAST MARRIAGE END? (3) '6 DIVORCE . (3) 0 ANNULMENT oP DEATH
C. DATE LAST MARRIAGE ENDED? 10 / 11 /20
MON'W' DA Y ~ - YEAR
D. ARE ANY FORMER SPOLlSE(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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 03/29/1989 Mocksville, N. C. 1':1
2ND 10/11/2003 Nassau County,N. Y.
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
YEAR
MONTH DAY
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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o 0
o 0
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is true an
o
o
21. SIGNATURE OF GROOM~
USE RRE NA
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New York State of the authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York Sta 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 ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Joh . Master on
{TIME MONTH DAY YEAR MONTH DAY
SEAL SIGNATURE" .
'-v-' M~t)l~~8'm'€b AM 12 14 2006 02 11 2007
STREET ZIP 03:48 PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY P'N7<"'dl"f'<<::
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF l&. VILLAGE OF
SPECIFY t/.~#hp:;./r~ s ~~S
TITLE
hs/'d'/o?
//6/07
, ,
DATE
31.
NAME (PRINT)
SIGNATURE"
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE"