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DISTRICT
NUMBER
REGISTER
NUMBER
:s I A II: Uf NI:W YUHK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Donald James Frederi~ Jr
MIDDLE CURRENT SU AME
~'''''I~II~'''' 1'1"'...........-.
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYfTOWN WaPlinger
1368
73
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~[rLEno.,nlit P~m'M SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
lL
N
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Fredericks
(OPTIONAL - SEE REVERSE) O:'7r L'D C,A88
D. SOCIAL SECURITY NUMBER -,L~_
12. RESIDENCE A. ~W'ediCl d B_ -~J~d
C. CHECK ONE D ~ITY D TOWN D VILLAGE
AND Os bu
SPECIFY n fYI
D. STREET ADDRESS 28 Rase Lane, AJ;t. 39 ZIP 08811
E IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORAlED VILLAGE? D~ES D NO
13. A. AGE ?4 3B. DATE OF BIRTH MOJf / DW /1WU-
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 040-72 1458
D. SOCIAL SECURITY NUMBER - - - -
2. RESIDENCE A. C"'..onner.licut B. Fairfield
(ST ATE) (COUNTY)
D ~ITY D TOWN D VILLAGE
Danbury
D STREET ADDRESS 28 Rose Lane. Apt. 39
C. CHECK ONE
AND
SPECIFY
ZIP 08811
D 'lfES D NO
11/ nR / 1Q7
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORAlED VILLAGE?
3. A. AGE 30
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION GrAphi~ OMigner
B. TYPE OF INDUSTRY OR BUSINESS Hersam & Acorn
15. PLACE OF BIRTH stamford, Connedicut
(CITY, STATE / COUNTRY IF NOT USA)
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A. . USUAL OCCUPATION Truck: Driver
B. TYPE OF INDUSTRY OR BUSINESS Modzele\NSkI TOINing
5. PLACE OF BIRTH Danbury. COnnecticut
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME GafYI Arthur Palmer
B. COUNTRY OF BIRTH USA
17. MOTHER
to-
=>
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C
A. NAME Donald James Fredericks. Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A, MAIDEN NAME Donns Louise Zerbarlnl
B, COUNTRY OF BIRTH USA
1
u..
c(
Sheryl Ann Dunlap
USA
8, NUMBER OF THIS MARRIAGE 1
18, NUMBER OF THIS MARRIAGE
A. MAIDEN NAME
B. COUNTRY OF BIRTH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULlMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
B, HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C, DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D, ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
C. DATE LAST MARRIAGE ENDED?
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o D
o D
o D
o D
eclare that no legal impediment exists
a:
06I14f2006
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21. SIGNATURE OF GROO
U
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 bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY,
D If checked, this license is tD be used only for the purpose of a second or subsequent ceremony,
24. TOWN OR CITY CLERK 25, A. SOLEMNIZATION PERIOD BEGINS
John C. M
MONTH
DATE
by New York Domestic
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{ } NAME (PRINT)
SEAL SIGNATURE ~
'-.t-I MAILI~~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED A80VE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
YEAR
TIME
MONTH
AM
06:4J.M
06
15
2006
08
13 2006
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTY Vvt-c~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF 'p!l TOWN OF D VILLAGE OF
SPECIFY uJtfr' I "')eA'
NAME (PRINT)
SIGNATURE~
DOH-9B (07/2005)
NAME (PRINT)
SIGNATURE~