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1. A. FUU. NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gbl-yne St8"Jt8&9nklin OURRENTSIRWIE
I
STATE RI..E__
(lHIS SPACE FOR STATE USE ONLY)
I
COUNTY n. rtr-he~~
CITYfTOWN Wappinger
~::~~ 136R
~5~~R 67
-.J
L 0 SUPPlEMENTAL RLE
FROM mE BRIDE
11.A AJu.tWIE J_IRose V'Jil~
QJRIIEM" SURliilME
lL
N
B. BIRTH NAME, IF OIFFERfNT
B. BIR11l NAME (MMIBllWlEl. If'DIRB8fT
c. ~~~evam&Gnklin
D. SOCIAl SEGUIlI1Y NUIiBER 109 60 5662
12. RESIllENCEA N_,K ork B. ~ss
C. CHECK ONE 0 CITY ~ TOWN 0 Vll.1.AGE
AND
Sl'ECIFY Wappinger
D. STREETADIlRESS 2365 Route 9d JIP. 12537
E. IS flESlDBa lM1HIN IJIIl1S OF CITY (Jl ~1ED l/IlJ.AGE? 0 YES g NO
13. A. AGE 28 sa. DATE OF IllmH IBm "1 ~y ~ii.
14. EMPLOYMENT
A. USUALOCCUPATlON Homemaker
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~M_,~tw.rYMk
16. FATHER
C. SURNAME AFTER MARRIAGE
(OPTiONAl- SEE REVERSE)
D. SOCIAL SECURITY NUMBER 111 72 9672
2. RESIDENCE A. N,*,,'f or:k e. ~e99
C. CHECK ONE 0 CITY iii TOWN 0 VIUAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 2~1;~ Ro'''e 9d
3. A. AGE 28
4. EMPLOYMENT
sa. DATE OF BIRTH
lIP. 12537
YES if NO
/ JS18
E. IS RESIDENCE WIl1iIN UMITS OF ClTV OR INOORPORAlEO VIUAGE? 0
dM /~
A. USUAL OCCUPATION Roefer
B. TYPE OF INDUSTRY OR BUSINESS ConstrudiOA
5. PLACE OF BIRTH PaR!IlllS_IJ'~. York
6. FATHER
A. NAME Miehael Richard VliIC)'
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME GwendOlyn Davis
B. QOUNTRYOFBlRTHU SA
18. NUMBER OF THIS MARRIAGE 1
19. ~R~~MARRlAGES WHICt'l ENDEDBV
DIVORCE CML ANNlJLMEM'
OEAlll
A. NAME ChaRes Lewis Conklin
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME lave", Eva Robinson
B. COUNTRY OF BIRTH I I S A
e. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
a:
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNUlJIENT (2) 0 DEA11l B. HOW OIl lAST UARIl1AGE END? c:ll 0 DMJRCE (Sl D AMNlllJIENf (2l 0 19TH
C. DATE LAST MARRIAGE ENDED? . / / C. DATE LASTMARRlAGE amED? / /
MONlli DAY YEAR - DAY rEM
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) AUVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOlJ..OW1NG INFORMATlON 20. IF PREVIOUSLY DIVORCED OR ANNuum. PROVIDE 1HE F01..1DWING 1MRJRMA1lON
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE P.LAOE ISSUED IlGIlINST WHllIM
(MONTH. DAY, YEAR) (CITYICOUNTY. STAlE/COUNlRY, IF NOT USA) SELF SPOUSE (MONTH. DAY, YEAR) (CI1YJOOONTY, SQl1EIGOlJN1ill(, IFIIIOTUSf\l SI3I.F SPOUSE
o 1~ 0 0
o 2ND [] []
o 3RD 0 0
o 4TH 0 []
lief thai the infonnation I provided is true implldiment exists
g
o
o
g
1ST
2ND
3RD
4TH
I duly swear/affirm, deP.<JS8 and saY. that to the best
as to my right 10 enter into th estate.
21. SIGNATURE OF GROOM"
DAle
by New
23. SUBSCRIBED AND SWORN TO/AFFIRMED.B
SIGNATURE OF TOWN OR CITY CLERK'- .
This license authorizes the marriage in New ork State of the bride and groom named above any peISOIl 8lJthoI;i2lllll
Relations Law !i11 to perform marriage ceremonies within New York State. THIS UCENSE VAUD IN NEW YORK STAlE ONLY.
o If checked. this license is to be used only for the pUlpOse of a second or t CIll8lOOIlY.
24. TOWN ORClTY CLERK 25. A. SOlEMNlZA11ON P$OO sEGl!ilS
~
{ } NAME (PRINT)
SEAL SIGNATURE"
MAILING ADDRESS
'-v-' .
1l'iEAR MONIIH
YEAR
TIME
MONIIH
06
03
2006
08 01 2006
28. PLACE WHERE MA'RmAGE 00ClIlRflED
A. STATE NEWYORK B.~
C. WGAlIION OF IQ6REMONV
(CHECK ONE AND 'SPEGlFll') ./
o en-< '" """'"'" ~''''~
SPECIFY W~
SIGNATURE" ·
DOH.98 (0712005)