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COUNTY Dutchess
CITYfrOWN Wappinger
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~~~I~~~R 85
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MAlvin Fllintt .Inhn~nn
MIDDLE CURRENT SURNAME
I
STATE FlL.E NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.Jackie L)lnn Williams
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
11.
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B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE .Inhn~nn
(OPTIONAL - SEE REVERSE) (OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 109-58-5398 D. SOCIAL SECURITY NUMBER 051-66-6267
2. RESIDENCEA. NAW Ynrk B. nlltr.hA~!,; 12. RESIDENCEA. NAW York 8. nlltchess
(STATE) (COUNTY) (STATE) (COUNTY)
C CHECK ONE 0 CITY 5/' TOWN 0 VILLAGE C. CHECK ONE 0 CITY r:Y TOWN 0 VILLAGE
~~~CIFY East Fishkill ~~~CIFY East Fishkill
D. STREET ADDRESS 37 Weitz Road ZIP 12533 D STREET ADDRESS 37 Weitz Road ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:5 NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
3. A. AGE 4~ 3B DATE OF BIRTH 1? / 03 / 1962 13. A. AGE 38 3B. DATE OF BIRTH 08 /29 /1967
MONTH DAY YEAR MONTH DAY YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION Warehouse Personnel
B TYPE OF INDUSTRY OR BUSINESS Waooinoer Cntrl Schl. Dist.
5 PLACE OF BIRTH Pouohkeeosie. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Elliott Farrell Johnson
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Beverly Tandy
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION School Bus Driver
B. TYPE OF INDUSTRY OR BUSINESS Wappingers Cntrl. Schl.
15. PLACE OF BIRTH Beacon, New-Vork
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Harold Robert Williams
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Theodora Jane White
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 3
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) d"bIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) d"bIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12/ 01 / 2004' c. DATE LAST MARRIAGE ENDED? 08 / 22 / 2003
MONTH oJ DAY YEAR MONT!:!...;o DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) AL.lVE? D"YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? LfYES 0 NO
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10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOL.LOWING 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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) . SELF SPOUSE
12/01/2004 Poughkeepsie, New York 0 d 1ST 02/24/1995 Poughkeepsie, New York d" 0
o 0 2ND 08/22/2003 Poughkeepsie, New York 0..... 0
o 0 3RD 0 0
o 0 4TH 0 0
knowledge and belief that the information I provided is tr e and that I declare that no legal impediment exists
, _ .J>
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USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. 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 CL,ERK C M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jonn . asterson
{SEAL SIGNATURE ~". DATE 06/28/200 TIME MONTH YEAR MONTH
'-v-I MAI~tOOtfdFe ush Rd, appinger Falls, NY 12590 04:31:~ 06 29 2006 08 27 2006
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YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PE -
SONS NAMED ABOVE ON T
DATE AND AT THE TIME A
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
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28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYlJUTC4f& j..;
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN ~ VILlLAGE OF
SPECIFY~ h~"I+1L.. ILL-
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~