147
co
I-N I-
zlt'\ -
~N >
w""" <(
~ C
51>" ~ u:
~ rz: :5 u..
~ --~ c:r:
o~ z
~=~
a:l'dc
~~ ~
fB,.cl ()
a:
W'''''
~=
ii'
a: ..
:i aJ
~a
~ aJ
~~
;::
a:~
~ ~
w I'd
a:
~ aJ II:
:;: =:JJ
UJ.~ ~
~l>~
a: a
~< ~
~o ~
~ -=- tn
"-
en
Ziz
~~g W
~~~ t-
I-ffiz <(
~dili 0
~~~ u:
z-
~~~ t=
&:oen a:
01->- W
w~C3 0
b~Uj
Z::i~
1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ja,ul .^.nlhonXlIM8 ReynO~~ENT SURNAME
I
::i I A II:. r-1L.t: RUMccn
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutche~~
CITYfTOWN Wappinger
~~J~~c~ 1368
~5~I~J~R 147
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME Sh~ Ann L1ot~IlEClunis
CURRENT SURNAME
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C S~~~~~JN~~~~~t~~e~~~eynold&
D. SDCIAL SECURITY NUMBER
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 101 68 4180
B D~ss
o TOWN 0 VILLAGE
12 RESIDENCE A.N~A~prk B. UI*llYl
C CHECK ONE 0 CITY 0 TOWN Iii! VILLAGE
~~~CIFY Highland
D STREET ADDRESs40 A Vjnp-yard A vp-nlJP- ZIP 17~7R
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES otJ NO
~NTH 14 DAV 19'8~AR
2. RESIDENCE A. N_T'l; ork
C. CHECK ONE o,lJ CITY
AND
SPECIFY Poughkeepsie
D STREET ADDRESS:3 Hamson street, Apt 2 ZIP 12601
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? @'J YES 0 NO
M~ /12v /1>>l
13. A. AGE20
14. EMPLOYMENT
13.8. DATE OF BIRTH
3. A. AGE 21
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15 PLACE OF BIRTHJ~m,fffi~oW~ ~~!~~
16. FATHER
W
I-
""
I-
en
A. USUAL OCCUPATION Cook
8. TYPE OF INDUSTRY OR BUSINESS IBM COrp
5. PLACE OF BIRTH ~eH,~~.&AJ~* York
6. FATHER
A. NAME
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Flor-eU:a S. Reynolds
8. COUNTRY OF BIRTH U 5 A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n
n
A. NAME Hopeton Lloyd Clunis
B. COUNTRY OF BIRTHTrelawny, Jamaica
17. MOTHER
A. MAIDEN NAME Rose Sheron stephens
8. COUNTRY OF BIRTHTrelawny, Jamaica
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
(2) 0 DEATH
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
C. DATE LAST MARRIAGE ENDED?
MONTH DAV YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DA V YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the m riage state. d"f) 1 ..
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE" ~un\6
r USE CURRENT NAME
DATE 11 {3n{7no~
by New York Domestic
w
(/)
Z
W
o
::::i
23. SUBSCRIBED AND SWORN TO FORE 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 mflrriage 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 CLERK .. _.~:. . 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John c:ua~~
SEAL ~~~I~~~5~ESS ~ Dl;S ZI~ DATE 11':30Q005
'-y-I ST~Q Middlebush Rd, Wapp~gret,faIl5, N'{TA.;t2590 ZIP
~~~R~~~Ri~~~ 10~Oi~~NifEE~ 26 SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 IrlELlGIOUS 10 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED 9 0 OTHER, SPECIFY
O11:vt4f .&.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
MONTH
DAY
YEAR
TIME
MONTH
AM
PM
12
01
2005
01
29 2006
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHYCK ONE AND SPECIFY)
Ii'CITY OF 0 TOWN OF 0 VILLAGE OF
IV f..W Sl/J?if d
SPECIFY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
ZIP
31. WITNESS TO CEREMONYL
NAME (PRINT) N i Co €3 G
SIGNATURE~ 41-/~
? E3/1S ~