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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
NmtuJn ~ AlainP-R
MIDDLE CURRENT SURNAME
COUNTY ~
C!:rvrrOWN Wappinger
~~J:~ 1388
~5~I~J~R 138
1. A. FULL NAME
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 141 """ ...7......
D. SOCIAL SECURITY NUMBER ___~L-~
2. RESIDENCE A. New Vark B. vv-t~lf~tp-r
(S'iA'i'E) ~
C. CHECK ONE (JI" CITY 0 TOWN 0 VILLAGE
AND
SPECIFY V onkerR
o STREET ADDRESS 23 EI'ees Lane 1&t Floor ZIP 10710
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE? oIvES 0 NO
MO~ /~ /'yW5
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
3_ A. AGE 29
4. EMPLOYMENT
3B. DATE OF BIRTH
L D SUPPLEMENTAL FILE
FROM THE BRIDE
YoIRnda L P8'm~r
MIDDLE CURRENT SURNAME
--1
A. USUAL OCCUPATION SanibJlinn WnrkP-r
B. TYPE OF INDUSTRY OR BUSINESS CIty 01 MOllnt Vernon
5. PLACE OF BIRTH ~j;tM~
6. FATHER
A. NAME I inwnnd Tlllnry
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME E\'-ORn. JohRSOR BaInes
8. COUNTRY OF BIRTH I J S A.
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
B. HOW DID LAST MARRIAGE-END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~nes
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER M~~
12. RESIDENCE A. N~EYnrk- B. ~~ester
C. CHECK ONE o;CITY 0 TOWN 0 VilLAGE
AND
SPECIFY VnnkP-~
D. STREET ADDRESS 23 EII~~ LAnA 1~ F=1~r
13.8. DATE OF BIRTH
ZIP 10710
YES r:::V NO
/1al~
(3) 0 ANNULMENT
/' /'
o
o
o
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE? 0
Mo1~ /' \~
13. A. AGE Zl
14. EMPLOYMENT
A. USUAL OCCUPATION T""~m~uni~ons Operator
8. TYPE OF INDUSTRY OR BUSINESS West. Med. ctr.
15. PLACE OF BIRTH ~~no~ Vodc
16. FATHER
A. NAME Vaughn Palmer
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Joan Franks
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
DEATH
o
o
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
o
o
1ST
2ND
3RD
o
o
o
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St E! of the ride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL}
'-v-I
NAME (PRINT)
1011812004
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
1011812004
AM
M
17 2004
10
19
12
ATE
27: TY70F CEREMONY
o ib/RELlGIOUS
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
ZIP
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRE~, I !,
A. STATE NEW YORK B. COUNTY~~
C. LOCATION OF CEREMONY
(C"GK ONE AND SPECIFY)
M CITY OF D TOWN OF 0 VILLAGE OF
SPECIFY M[ f/p'7!1Jl/1
SIGNATURE