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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.Iw~tin M;::ltthp.w .I;::lmi~nn
MIDDLE CURRENT SURNAME
COUNTY Dutchess
C1TYfTOWN Wappinger
~~~:~c: 1368 '
~5~~l~R 147
1 ' A, FULL NAME
FIRST
Q.
N
B, BIRTH NAME, IF DIFFERENT
I
STATE FilE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
C, SURNAME AFTER MARRIAGE
D, ~:~~~~:~U~~~~RSE) 133-72-4045
2, RESIDENCEA Npw York B, nlltr.hp.~~
(STATE) (COUNTY)
C, CHECK ONE 0 CITY 0 TOWN [yo' VilLAGE
~~~CIFY Fi~hkill
D, STREET ADDRESS 1290 Hopewell Avenue
ZIP 12524
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 01 YES 0 NO
MONtt2 / DA~ R / YEAt 9R
3, A, AGE 25
3B. DATE OF BIRTH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Am~ L. Muir
MIDDLE CURRENT SURNAME
-1
4. EMPLOYMENT
w
A. USUAL OCCUPATION ~hp.p.t Mp.t;::ll Wnrkp.r
B, TYPE OF INDUSTRY OR BUSINESS Elmsford Sheet Metal
5. PLACE OF BIRTH Rp.;::lr.nn, NBW Yark
(CITY. STATE I COUNTRY IF NOT USA)
11. A. FULL NAME
FIRST
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Jamison
(OPTIONAL - SEE REVERSE) 106 70 2603
D, SOCIAL SECURITY NUMBER --
12, RESIDENCEA. New York B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY 0 TOWN 01 VILLAGE
~~~CIFY Fishkill
D, STREET ADDRESS '1290 Hopewell Avenue ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? rf YES 0 NO
05 /30 /1979
MONTH DAY YEAR
13. A. AGE ?7
3B. DATE OF BIRTH
6. FATHER
A. NAME lE>ffrE>Y Willi;::lm .1<3mi~nn
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME ~11~;::ln Amy DBmp.r~
B. COUNTRY OF BIRTH I J ~ A
B. NUMBER OF THIS MARRIAGE 1
9. ~~~~~IM~RM6'FR~~~T8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
(2) 0 DEATH
14. EMPLOYMENT
A. USUAL OCCUPATION Charter Coordinator
B. TYPE OF INDUSTRY OR BUSINESS Citation Shares
15. PLACE OF BIRTH Grand Forks. North Dakota
(CIlY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME AlfrBd Will/iam Muir. Jr.
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Susan Lynn McCelland
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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) (CIlY/COUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 D 0 0
2ND 0 0 0 0
3RD 0 D 0 0
0 0
al impediment exists
23. SUBSCRIBED AND 'SWORN
SIGNATURE OF TOWN, OR ClERK"-
This license authorizes the marriage in New 'York State of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York tate. 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
~
{ SEAL}
'-v-I
NAME (PRINT)
STREET
I CERTIFY THAT I SOlEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
fT N
28. SOLEMNIZATION OCCURRED
TIME 0 DAY YEAR
3 ~M J6-~O'Ol.,
29. OFFICIANT 0 e Ii D r1 . 0 I J /,
NAME (PRINT) i\ . Y". ().rH~/ 0 K€.- CV /H1.
"G""_~ g.:u 1)"" '~ lA ~
MAILING ADDRESS '_
/.,gO 'Ro"t1!. 3 1- (p a~lt>iVl~.u. /-17 lis
STREET CITYfTO III
30. WITNESS TO C~M .--
NAME (PRINT) (2...,
TIME
MONTH
YEAR
AM
03:4~M
09
STATE
27. TYPE OF CEREMONY
oN RELIGIOUS
9 0 OTHER, SPECIFY
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ]}v+c.k-tn
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF lfTOWN OF 0 VILLAGE OF
SPECIFY Wa ffi" \.1 g e.. r-
TITLE -1:1; ~i s t-e v
DATE 10 -20 - () ~
JUV
STAtE
SIGNATURE"-
DOH-98 (0312006)