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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
D,~I Lee Bau;~
COUNTY Dutchess'
CITYfTOWN Wappinger
~~J~kc; 1 :\fiR
~Q~I~J~R 1 :\n
1. A. FULL NAME
CURRENT SURNAME
a.
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 519-31-8378
2. RESIOENCE A. N~T~odc B. ~~~
C. CHECK ONE 0 CITY 0 TOWN ~ VilLAGE
~~~CIFY Wappingerg Fall~
D STREETADOREss40 Clapp Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 'tJ YES 0 NO
3. A. AGE2" 3B.DATEOFBIRTH "1 /<10 /10g'J
.eo M~H -tD1\Y "Y'eAl'l.JI
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4. EMPLOYMENT
A. USUAL OCCUPATION ~ale~
B. TYPE OF INDUSTRY OR BUSINESS RayrnolJr & Flanigan
5. PLACE OF BIRTH Boise Idaho
(CITY, SrATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Darvin Ramhill
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy Christine Barrett
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
DEATH
o
(2) 0 DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY 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
I
:) I A I E: riLe. nUMcu;n
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
~
11. A.
FROM THE BRIDE
FULL NAME KeilMis Emily ~iQer
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~ar:rett
(OPTIONAL - SEE REVER~
D. SOCIAL SECURITY NUMBER 063-6&-1959
12. RESIDENCE A-N.A~dc B D~~s
C. CHECK ONE 0 CITY 0 TOWN ~ VilLAGE
~~~CIFYWapp~nge~ F~lls
o STREET ADORESs40 Clapp A venue ZIP 1 :;159n
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE22 13.B. DATE OF BIRTH ~ 'l eJ2 1H?
MONTH DAY ~AR
14. EMPLOYMENT
A. USUAL OCCUPATIONCudnUler Service
B. TYPE OF INDUSTRY OR BUSINESS RaY"' ollr & Flanigan
15. PLACE OF BIRTHRp.acon New York
(CITY, STAT~COUNTRY IF NOT USA)
16. FATHER
A. NAME~ir.hard Rnlr.e 71'1r.her
B. COUNTRY OF BIRT.t J ~ A
17. MOTHER
A. MAIDEN NAME Nancie lee lbomp~on
B. COUNTRY OF BIRT.t J ~ A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY 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
o 1ST
o 2ND
o 3RD
o 4TH
belief that the information I provided is tru
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23. SUBSCRIBED AND SWORN RE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e of the bride and groom named above by any person authorized
Relations Law ~11 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 ClERI$.,,,,:. . '.' '. . 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) JOh~~
SEAL SIGNATURE ~ ~ C7l/~ DATE 1010612005
MAILING ADDRES;b . 11 :28 AM 10
'-v-I sTt9T Middle ush Rd, Wappi~!'wfalls, N~Jf590 ZIP PM
~~~R~~RT~~~ IO~O~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 [lYRELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
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TITLE
DATE
iJ'/
STATE
SIGNATURE ~
DOH.98 (11/98)
,
TIME
MONTH
YEAR
MONTH
YEAR
07
2005
12
05 2005
10 CIVil
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ll/i7J4M
PAS7tJ!<
/6 19 IdS-
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/;;rl~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~llLAGE OF
SPECIFY (1t-O SP/</N G-
NAME (PRINT)
SIGNATURE ~
31. WITNESS TO