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COUNTY C>~~
CITY/TOWN Wappinger
~~~~~~ 1368
~G~I~J~R 42
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Richard Johnson
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rachel Ann Marle Tolliver
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
CURRENT SURNAME
CURRENT SURNAME
FIRST
MIDDLE
MIDDLE
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Johnson
(OPTIONAL. SEE REVERSE) 109-62-4370
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B C>utchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 ~OWN 0 VILLAGE
~~~CIFY WaQf:1in~r
D. STREET ADDRESS 120 Osborne Hill Rd. Apt. ZIP
E. IS RESIDENCE WITHI~I~I~ OF CITY OR INCORPORATED VILY!? 0
13. A. AGE 27 13.B. DATE OF BIRTH 05 / 11
MONTH DAY
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 062-72-1939
o SOCIAL SECURITY NUMBER
2 RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cYTOWN 0 VILLAGE
D. :~:~~7ADD:a~~borne Hill Rd, Apt. ZIP
E. IS RESIDENCE WITHIN ~M~T; OF CITY OR INCORPORATED VILtPJr 0
3. A. AGE 24 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Network Administrator
B. TYPE OF INDUSTRY OR BUSINESS H. V. F. C. U.
5. PLACE OF BIRTH Greenwich. Connecticut
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Chief Of staff
B. TYPE OF INDUSTRY OR BUSINESS N Y S Assembly
15. PLACE OF BIRTH Mount Kisco. New York
(CITY, STATE/COUNTRY IF NOT USA)
12590
YES 0'" NO
/i 978
YEAR
12590
YES d'" NO
6. FATHER
16. FATHER
A. NAME Robert O. Tolliver
B. COUNTRY OF BIRTH USA
17. MOTHER
A. NAME Daniel Barker Johnson
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Celeste Marie VA77sna
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
A. MAIDEN NAME Blythe H Miller
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(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 F.OLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
exists
.--
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa
as to my right to enter into the mar'
21. SIGNATURE OF GROOM ~
o
o
o
o
o
o
w
en
z
w
()
:J
23. ~~JJT~~~Do~N~~~OcfRN~~Bg~~~~E DATE 05/31/2005
This license authorizes the marriage in New York St the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew 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 CLER!< 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glons J. Morse
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ 05131
'-v-' MAI~tf,gebush R Falls NY 12590 AM 06
STREET STATE ZIP 12: 1 ()>M
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- _ ./
SONS NAMED ABOVE ON THE 0 ID-1'lELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED.
-----
29. OFFICIANT )-
NAME (PRINT)-....J?
YEAR
01
2005
07
30 2005
10 CIVIL
28. PLACE WHERE MARRIAGl5~
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ OF 0 VILLAGE OF
SPECIFY ~fi ~
NAME (PRINT)
SIGNATURE