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1. A, FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Jas~QD~ayne TO~Rl<J~~RNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:f: 1368 .
~5~':~R 153
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Marie Ulland
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 Tompkins
(OPTIONAL, SEE REVERSE) 059-72-3115
D, SOCIAL SECURITY NUMBER
12, RESIDENCEA. New York B, Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r1 TOWN 0 VILLAGE
~~~CIFY Wap~inaer
D. STREET ADDRESS 14 Cindy Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d' NO
08 / 10 /1980
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 114-68-3893
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY r!I' TOWN 0 VILLAGE
~~~CIFY Wappinqer
0, STREET ADDRESS 14 Cindy Lane
ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [j' NO
04 / 12 / 197
MONTH DAY YEAR
13. A. AGE 26
3. A. AGE 29
3B. DATE OF BIRTH
3B. DATE OF BiRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Floorinq Installer
B. TYPE OF INDUSTRY OR BUSINESS Self Employed
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Domestic Engineer
B. TYPE OF INDUSTRY OR BUSINESS Homemaker
15. PLACE OF BIRTH Poughkeepsie. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert R. Ulland
'B, COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mary C. Donnelly
B. COUNTRY OF BIRTH Germany
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVil AN~lMENT
6. FATHER
A. NAME Wayne Tompkins
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Cecelia Darcy
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MAR81AGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
De.crH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID 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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
Y knowledge and belief that the information I provided is t
,
o 0
o 0
o 0
o 0
and that I declare that no legal impediment exists
.~
USE CURRENT NAME 09/13/2006
USE C RRE
23. SUBSCRIBED AND SWOR T FFIRMED BEFORE ME
SIGNATURE OF TOWN OR CLERK ~
This license authorizes the marriage in New York State 0 the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New Yo State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pu se of a second or subsequent ceremony.
r-"--. 24. TOWN OR CITYJCll=RK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) onn n
{SEAL SIGNATURE ~ DATE 09/13/200 TIME MONTH YEAR MONTH
'- -.J MAI~5mme ppinger Falls, NY 12590 ,j'.M 09 14 2006 11 12 2006
-v- 03:5q,M
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 0 RELIGIOUS 1 CIVil
DATE AND AT THE TIME AND r
PLACE INDICATED, 2--Z-r 010 9 0 OTHER, SPECIFY
DATE
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY (');tJIlfJcll.
29, OFFICIANT
NAME (PRINT)
C. lOCATION OF CEREMONY
(CHECK ONE AND yeCIFY)
o CITY OF .r2rjOWN OF/ CJ VilLAGE OF
SPECIFY#~ ~/V~.f"~L.
U,t-
SIGNATURE