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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 n. N - 1i ....LL. z w U) W III 91: e 5"-l'6I.L 1Jj -,I.L z;:m ~ <( o z !;i ~ a: I:: tn .~ ffi ::t () iJ ~'t! ::Em ~:3 ~lij <( o ~~ w o w a: w :r: ~ U) U) w a: o o <( >- LL (3 W n. U) ~:i:z ::lcQ tij~~ a:"'N ~~~ ::lUW ::2,,5 ....zu) z- ~~~ tl:ow 01->- w~C3 b~"' Z:::i~ o 1ST 0 0 o 2ND 0 0 o 3RD 0 0 o 4TH 0 0 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 ~..r/ .... S; <( 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 a: w III ::;; :J Z o Z <( I- W W a: I- '" 21. SIGNATURE OF GROOM ~ w CJ) z w o ::::i ~ { SEAL } '-v-I 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 ~