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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RCXBeV.MnRI~
FIRST MID
r-
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYfTOWN \Napplnger
~~J~~c~ 1388
~5~lgJ~R 131
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME NaimA .lohMnn
FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)ftJ:' ~ ~~. 1M'f:'78
D. SOCIAL SECURITY NUMBER ~~
2. RESIDENCE A. ~ Vark B. nutm.-..
~T{) (COUNTY)
C. CHECK ONE D CITY tt\ TOWN D VILLAGE
AND We .
SPECIFY panger
D. STREET ADDRESS 77 Kretch Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? D YES ~ NO
3. A. AGE .43 38. DATE OF BIRTH M~ / 1D~Y / tll1
4. EMPLOYMENT
A. USUAL OCCUPATION Correction omcer
8. TYPE OF INDUSTRY OR BUSINESS Westchester County
5. PLACE OF BIRTH Charlotte. Vlldnle
(CITY, STATE/COUNTRY,"NOT USA)
6. FATHER
A. NAME utell Mosley
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME I 1\1..... ~
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
B. BIRTH NAME (MAIDEN NAME), IF. DIFFERENT
c. S~~~~~M!Z~~~t~~eg~s~osIev
D. SOCIAL SECURITY NUMBER 115-58-1040
12. RESIDENCEA.~ork B.~
(A) ~
C. CHECK ONE CITY D TOWN D VILLAGE
~~~CIFY Mount Vernon
D. STREET ADDREss348 Gerden Avenue ZIP 10553
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES D NO
13. A. AGE 30 13.B. DATE OF BIRTH ~NTH .(8 DAY 187~R
14. EMPLOYMENT
A. USUAL OCCUPATION Correction omcer
B. TYPE OF INDUSTRY OR BUSINESS Westchester County
15. PLACE OF BIRTH New Rochelle New York
(CITY, STATE/COUNTRY I~ NOT USA)
16. FATHER
A. NAME Gregory Johnson
B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Leo Harper
8. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? Q2 /08 /2001
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES D 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 02lO8l2OO1 WhIte PI"... New York D r!!!
D
D
DEATH
o
DEATH
o
(2) D DEATH
(3) D ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
YEAR ~;
MONTH DAY
D. ARE ANY FOR~ER SPOUSE(S) ALIVE? DYES D NO ..... .. .. f;,.
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORM/(troN
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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2ND
3RD
4TH
I, being duly sworn, depose and
as to my right to enter into the"
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21.
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subse uent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) ;p;. Masterson
{ SEAL SMIGNATURE~. C~~ DATE1Of11/2005
'-.,-I ~WcB Rd, ~nger Falls. NY 12590 10:47 AM 10
STREET CITYITOWN STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 D RELIGIOUS 1 IVIL
~tl~E ~~glt:TJ~E TIME AND 9 D OTHER, SPECIFY
12
10 2005
YEAR
MONTH
YEAR
TIME
MONTH
2005
12
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
D CITY OF '0 TOWN OF ~ILLAGE OF
lJCIFY~dfM ~
30. WITNESS TO CER ONY n
NAME (PRINT) · ~\ ~ 'E..2.\1') r__ \ 0 ~\..e..e.Xt-ex- NAME (PRINT)
SIGNATURE ~. ~ / 1~~ ' ~ -= ~ 0...1 0 ~
DOH-98 (11/98)