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COUNTY
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher Michael Edwards
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
Dutchess
Wappinaer
1368
34
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kecia Lashawn Milton
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 098-72' A~I'\A
D. SOCIAL SECURITY NUMBER --~
New York
(STATE) ~.
o CITY 0 T~N
Wappingers
8 Alpine Drive Ad. E
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Edwards
(OPTIONAL - SEE REVERSE) 11 ~ ~ AI:"')5
D. SOCIAL SECURITY NUMBER ~'"
12. RESIDENCEA. New York B Dutchess
(ST A TEl - . (COUNTY)
o CITY 0 TcJWfN 0 VILLAGE
Wappinger
8 A1Dine Drive ADt. E
2. RESIDENCE A.
B. (COut;?'iYlflchess
o VILLAGE
C. CHECK ONE
AND
SPECIFY
1259"
DYESDN~
04/ 198~
DAY YEAR
C. CHECK ONE
AND
SPECIFY
D. STREET ADDRESS
D. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
01/
MONTH
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
;;>?
13.B. DATE OF BIRTH
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24
MONTH
. A. AGE
3B. DATE OF BIRTH
3. A. AGE
14. EMPLOYMENT
4. EMPLOYMENT
Lost Prevention Manager
B. TYPE OF INDUSTRY OR BUSINESS K- Mart
15. PLACE OF BIRTH Sharo~ Connecticut
(CITY, STATE/COU RY IF NOT USA)
16. FATHER
A. NAME
>"
Z
A. USUAL OCCUPATION Sanitation
B. TYPE OF INDUSTRY OR BUSINESS Isabella city Carting
5. PLACE OF BIRTH Manhattan. New V ork
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION
6. FATHER
Eddie Gene Milton. Jr.
USA
A. NAME Michael Carrington Edwards
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gall Evely~ Br~
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
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME ~ir.hpJlp- AntninP.ttp- PAntin
B. COUNTRY OF BIRTH England
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DEATH DIVORCE CIVIL ANNULMENT
o 0 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNUUMENT
/ /
(2) 0 DEATH
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
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
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the be
as to my right to' enter into the marriage
21.
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
of my knowledge and belief that the information I provided is true and t
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23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State
Relations Law ~11 to perform marriage ceremonies within N 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 }
~
NAME (PRINT)
SIGNATURE ~
MAILING ADDRE:?S
TIME
MONTH
YEAR
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 OCCURRE~_ I ,I
A. STATE NEWYORK B. COUNTY~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY '. J )a f,j) h1'f r
..,-,
29. OFFICIANT
NAME (PRINT)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ~ )1)
~
SIGNATURE ~ ..--
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-...- ~ ?-