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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nikolas Richard Ravmond
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~~ 1368 '
~~~I:J~R 154
1 , A, FULL NAME
FIRST
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 04-64-4059
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUN1Y)
C, CHECK ONE 0 CITY cf TOWN 0 VILLAGE
~~~CIFY NewburCh
D. STREET ADDRESS 40 eslie Road ZIP 12550
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILlAGE? 0 YES r1 NO
3. A. AGE 25 3B.DATEOFBIRTH 01 / 26 / 198
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION H V A C
B. TYPE OF INDUSTRY OR BUSINESS Heating & Air Condo
5. PLACE OF BIRTH Cold Spring, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Richard Kenneth Raymond
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jessica Rodino
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV07rE CIVIL ANN~MENT
DEAlr
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACEJ,OR STA TE USE ONL Y)
I
Lo
~
SUPPLEMENTAL FILE
FROM THE BRIDE
Danielle Irene Mc Cormick
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ravmond
(OPTIONAL - SEE REVERSE) 129-68-2395
D. SOCIAL SECURIlY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE).-J (COUNTY)
C. CHECK ONE 0 CITY LI TOWN 0 VILLAGE
~~~CIFY Newburgh
D. STREET ADDRESS 40 Leslie Road ZIP 12550
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILlAGE? 0 YES d NO
06 /30 /1983
DAY YEAR
13. A. AGE 23
3B. DATE OF BIRTH
I
14. EMPLOYMENT '
A. USUAL OCCUPATION Waitress
B. TYPE OF INDUSTRY qR BUSINESS Cracker Barrel
15. PLACE OF BIRTH Ft. Lauderdale, FlOrida
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Hugh Allen Mc Cormick
'B. COUNTRY OF BIRTH USA
MONTH
17. MOTHER
A. MAIDEN NAME Renee June
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V~CE CIVIL AN~LMENT
D'1)H
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
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE . PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
nowledge and belief that the information I provided is tfile a
by New York Domestic
e bride and groom named above by any person authorized
tate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
only for the purpose of a second or subsequent ceremony.
25. A. SOLlEMNIZATION PERIOD BEGINS
ZIP
11
18 2006
1ST
2ND
3RD
4TH
I duly swear/affirm, dep-ose and say. that to the best of my
as to my right to enter into the r age state.
21. SIGNATURE OF GROOM'-
USE CU E NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of
Relations Law ~11 to perform marriage ceremonies within New York
o If checked, this license is to be use
.-A- 24. TOWN OR CITY CL~RK C M t
r- ~ JOnn . as erson
{ } NAME (PRINT)
SEAL SIGNATURE ~
MAIL~~a1
'-.t-I
STREET ClTYfTOWN STATE
~~R~~RTr~J IO~O~~N:.z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M . AY YEAR O~RELIGIOUS
~tl~E~gltA~~E TIME AND S.oD A d{ - '1"2..- ace, 90 OTHER, SPECIFY
YEAR
MONTH
YEAR
09/19/200
DATE
ush R ,Wappinger Falls, NY 12590
2006
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY R.t,trAf'Vl
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 'If VILLAGE OF
SPECIFY Lb~c1 'Sf' l n ,
~~~_ ~ muo:n\CLl~l>~\E-5.
SIGNATURE ~ . ,,().. /' DATE c;q - 2..2.. C)~
MAILING ADDR S y-
:2l-\~{\2..~' OOL~ 5(?R\~, N ~ I p:::frl to
STREET CITYfTOWN ST
30. WITNESS TO CE
NAME (PRINT)
SIGNATURE~
31. WITNESS TO