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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
8teMheA Afthll'o~es CURRENT SURNAME
1ST 11/1&t2005 Poughkeepsie, NI\A:YOFIc II 0 1ST 0IQ3Q000 PoughkMp5Ie, NewYoFk II 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my Isoowledge and belief that the information I provided is true and that I de"Clare that no legal impediment exists
as to my right to enter into the m mage state. ~ . -,
21.SIGNATUREOFGROOM~22.SI J"UREOFBRID~~ .l'11/1''(lJA(./ M?/-r.J? f lO
'USE E [) USE CURRENT NAME -
23. ~~~:~~~oo~N1o~~00~ ci~A6r~:E~ BEFORE ME DATE 05f.25I2006
This license authorizes the marriage in New York State of by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York te. THIS UCENSE 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
COUNTY Dutchest
CITYfTOWN Wappinger
DISTRICT
NUMBER ~ 3S8
REGISTER 60
NUMBER
1. A. FULL NAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 072 && -4256
2. RESIDENCE A. N_~Dfk B. ~
C. CHECK ONE 0 CITY,jjji TOWN 0 VILLAGE
AND
SPECIFY 'lJappiAger
D STREEJ ADDRESS 24 Doyle DIWe ZIP 125SK3
E. IS RESIDENCE WITHIN L1MIJS OF CfTY OR INCORPORATED Vlu.AGE? 0 YES ~ NO
Mc02 / 22 / 49S6
3. A. AGE 40
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION H8IIIing & Air CeAdliBning
B. TYPE OF INDUSTRY OR BUSINESS All Temp HelIng
5. PLACEOFBIRTH~I*.Ad
6. FATHER
A. NAME JohA Lee FergBes
B. COUNTRY OF BIRTH U S .'\
7. MOTHER
A. MAIDEN NAME AnA Miry Judg6
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) .. DIVORCE (3) 0 ANNULMENT (2) 0 llEAlH
C. DATE LAST MARRIAGE ENDED? MONTH 11 / 01$ / 2QP6
D. ARE ANY FORMER SPOUSE(S) ALIVE? IijIlfES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CIlYICOUNTY. STATEICOUNTRY. IF NOT USA) SElF SPOUSE
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{ SEAL }
'-v-'
NAME (PRINT)
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE~
DOH-98 (0712005)
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
.-J
11. A.
FROM THE BRIDE
FULL NAME JefiIIifer LynA Mitehell
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Balluff
C. SURNAME AFTER MARRIAGE 1:0-
(OPTIONAL - SEE REVERS") '..--
D. SOCIAL SECURfTY NUMBER 054 5&-871-4
12. RESIDENCE A. NewA~prk B. O'*b'lS8
C. CHECK ONE 0 CITY IWi' TOWN 0 VILLAGE
AND
SPECIFY ~JappiRger
D. STREEJ AOORESS22 SeIfour OM ZIP 12590
E. IS RESIDENCE WITHIN UMIJS OF CfTY OR INCORPORATED VIu.AGE? 0 YES.jlI NO
ram 1aAY 19"&
13. A. AGE 35
14. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION HlliRiresser
B. TYPE OF INDUSTRY OR BUSINESS Fantestle cuts
15. PLACE OF BIRTHT~~~a-JYGFlc
16. FATHER
A. NAME WHiBm KBFI BBlluIf, Jr.
B. COUNTRY OF BIRntJ S .~,
17. MOTHER
A. MAlDEN NAME rGtrlell MA Freer
B. COUNTRY OF BIRnt) S ^
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B..HOW DID LAST MARRIAGE END? (3) !iilDIVORCE (3) 0 ANNULMENT (2) 0 DEAlH
C. DATE LAST MARRIAGE ENDED? "8 / ~ / 'VVV\
M~lfIii' iI8Jiif ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? IiijlIYES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CnYICOUNTY. STATEICOUNTRY. IF NOT USA) SELF SPOUSE
TIME
MONTH
YEAR
MONTH
YEAR
11:51 AM
PM 05
07
242006
26
2006
ZIP
1~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou~().77 ,JftJ
C. LOCATION OF CEREMONY
(CHECK ONE ANV"PECIFY)
o CITY OF I!1'TOWN OF 0 VILLAGE OF
SPECIFY wA{J(f7, rv6'Vl .
ZIP
31. WITNESS TO CEREMONY, \ A I ettli
NAME(PRINT)~o.xlA-- flU. no
SlGNAruRE~ ~'" ~