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006
STATE OF NEW YORK I STATE FILE NUMBER I
COUNTY Dutchess (THIS SPACE FOR STATE USE ONLY)
CITYrrOWN ,Wappinger DEPARTMENT OF HEALTH
~1fJ~~~ 1368 AFFIDAVIT, LICENSE and
~5~~J~R 6 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME ~ Williams FaunUer~ 11. A. FULL NAME C~I Renee Norman
FIRST IDDLE CURRENT SU AME FIRST MIDDLE CURRENT SURNAME
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ge and belief that the information I provided is trU/fd that I declare th~t no legal impediment exists
. 22 IGNATURE OF BRIDE ~ -kGl .?"Ji}-czii ~A- 4~../'-
~RRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~ DATE n?1t\4~
This license authorizes the marria e in f the bride and groom named above by any person authorized by New York Domestic
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
NAME (PRINT) ~mia .1
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B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 117 11:: A 3503
D. SOCIAL SECURITY NUMBER - -_.~-
2. RESIDENCEA. NewVork B.. Dut~
(SWE) (coumv,-
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY W8PJjngers Falls
D. STREET ADDRESS 25 stuart Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r'!! YES 0 NO
3. A. AGE 35 3B. DATE OF BIRTH M~ / ~ / Uf9
4. EMPLOYMENT
A. USUAL OCCUPATION Courier
B. TYPE OF INDUSTRY OR BUSINESS staples Oelivel)' 8er
5. PLACE OF BIRTH Manhatta~NAW V orlc
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Unknnwn
B. COUNTRY OF BIRTH U 8 A
7. MOTHER
A. MAIDEN NAME Freddcka Emestl~e Fauntleroy
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH OAY 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
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21. SIGNATURE OF GROOM ~
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a. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE S:auntlpJnY
(OPTIONAL. SEE REVERSE) .-.nn
D. SOCIAL SECURITY NUMBER 0Q4. 7R......~.,l.J3
12. RESIDENCE A. New V ork: B. Dl.rtl"'h~
""(S'I'ATE) (CO~)
C. CHECK ONE 0 CITY 0 TOWN IY'VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 25 stuart Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r!! YES 0 NO
13. A. AGE 29 13.B. DATE OF BIRTH ~H /2Iy .{91~
14. EMPLOYMENT
A. USUAL OCCUPATION Selling A.CL!omdate
B. TYPE OF INDUSTRY OR BUSINESS Kohlls O. store
15. PLACE OF BIRTH Bronv New York
(CITY, STA"E/COUNTRY IF NOT USA)
16. FATHER
A. NAME Irvin Nnrman
B. COUNTRY OF BIRTH U 8 A
17. MOTHER
A. MAIDEN NAME Joa~~ Randolph
B. COUNTRY OF BIRTH USA
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
TIME
MONTH
YEAR
MONTH
YEAR
IP
~~
AM
PM
02
05
04
05 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~3)i~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY O~WN OF 0 VILLAGE OF
\ ,f)" t.,q ,r-
SPECIFY ~\ 11....) e (
NAME (PRINT)
SIGNATURE ~