145
o
m
U)
('II
~
>=
z
j
~
fit
I
I
c::
f
3
:Ii.
J
i
~
W
em
I
;:
m
m
W
c::
o
o
<<
>-
LL
o
W
0-
m
~:i:z
:Jt:Q
>-;:>-
~~~
>-WZ
m-,::>
:::lOW
~(!)c5
>-zm
Z-
n~~
~OCJ)
0>->-
W~(3
b~Ln
Z:i~
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Arp.nt Clevp.IAf'1d Slough
FIRST MIDDLE
r-
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYrrOWN Wappinger
~~J:~CRT 1368
~5~~J~R 145
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULLNAME Ni~W H. MonfwJ!LE
CURRENT SURNAME
CURRENT SURNAME
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE '::::Ioygh
(OPTIONAL - SEE REVERS~
D. SOCIAL SECURITY NUMBER 125 70 71fH
12. RESIDENCE A.N~STATE) B. D~&&
C. CHECK ONE 0 CITY III TOWN 0 VILLAGE
ANOn "'k .
SPECIFY rOUg.. eepsle
D. STREET ADDRESsQ Kimhp.rIy ~nlJrt ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
'WNTH 20 DAY 1~R
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 631-05-9027
2. RESIDENCE A. N~~eA B. (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND
SPECIFY I as Vegas
D. STREET ADDRESS 3650 Ash Springs Way ZIP 89129
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 22 3B. DATE OF BIRTH M!tt / \'lv /1.iD3
4. EMPLOYMENT
A. USUAL OCCUPATION InfAntry nffi~er
B. TYPE OF INDUSTRY OR BUSINESS US Army
5. PLACE OF BIRTH ~:~~~T~~~~~"N!recl:!C
6. FATHER
A. NAME Wade MAnr.hell ~lnlJgh. .Ir
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME pAJI"ela Ann Sykes
B. COUNTRY OF BIRTH l J ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
13. A. AGE 20
14. EMPLOYMENT
13.B. DATE OF BIRTH
w
>-
'"
I-
m
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Montserrat College Of Art
15. PLACE OF BIRTH~n.\lrJg~f)!X
16. FATHER
A. NAME Nicholas Patrick Monfor.li
B. COUNTRY OF BIRTf-( J ~ A
17. MOTHER
A. MAIDEN NAME Kimberly S. Hasrla
B. COUNTRY OF BIRTf-Il 5 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
t-
=>
<
c
w -
toLL
:5LL
~<
z
;;:
o
~
>-
C3
DEATH
DEATH
o
o
B. HOW OlD LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
YEAR
YEAR
a:
w
aJ
::;
:::l
Z
Cl
Z
<<
I-
W
W
a:
....
00
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 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 impedim nt exists
as to my right to enter into the marriaQ!; tate. .
'" . I
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
w
en
z
w
()
::i
23. SUBSCRIBED AND SWORN TO 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 911 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by New York Domestic
~
{ SEAL}
'-v-'
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
11:24 AM
PM 11
2005
01
24 2006
26
ZIP
CI rrOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
1 ~ CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY R-thh.~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF K TOWN OF 0 VILLAGE OF
SPECIFY f~\\\ \~&~{\
o 0 RELIGIOUS
"3 ~O\) M \ 2.. \ ~ OS 9 0 OTHER, SPECIFY
W
~ ~~~l~~~~~r. HON. JAMES D. P~ONES TITLES'J((O~oi:w G\l(t 0v
~ SIGNI~~~E~Ess4.w.fA-'<l o-~-- DATE ~~r \<6J2005
~ ~~r~O"$~; \0 MG-.(''K~-k SIt.) ~"\J ~"\..~'ll.l N'{ \1-(,,0\
W STREET CITYrrOWN ~ -mTE ZIP
o "''''''''0 ''''"~ / I ''''.'''''"0 """0"'
:::::: tt.;;t- W!~" :m:: :~:::: (I
DOH-98 (11/98)