124
0-
N
I-
Z
W
Ul
W
In
o
.....
::>
o
:I:
Ul
Z
o
~
a::
I-
Ul
a
w
a::
w
Cl
..
~
a::
..
=<
lI-
o
W
!;(
<.)
u:
;::
a::
w
<.)
w
a::
w
:I:
;:
Ul
Ul
w
a::
o
o
..
>-
lI-
U
W
0-
Ul
I-
:;
c:e
Q
u:
u.
-c:e
a:
w
III
::;
::l
Z
o
Z
..
Iii
w
a:
>-.
Ul
~:i:z
::>t:Q
1-;:>-
~~~
I-WZ
Ul.....=<
::l<.)W
=<Cl5
I-ZUl
Z-
~~~
[ow
01->-
U,i~C3
b~~
Z:J~
COUNTY 'Dutchess
CITYITOWN WapDInger
1368
124
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Justin J. Tomlins
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
DISTRICT
NUMBER
REGISTER
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Hesther E. Weldon
MIDDLE CURRENT SURNAME
-1
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Tamlins
(OPTIONAL - SEE REVERSE) nn.. en~E.12
D. SOCIAL SECURITY NUMBER ~
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D IlfOWN D VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 125 New Hambura Road ZIP
12537
YES D"NO
/1973
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) i'VVlI-72 9860
D. SOCIAL SECURITY NUMBER "W'V-.
2. RESIDENCE A. New York B. DuIchesB
(STATE) (COUNTY)
C. CHECK ONE D CITY D-'l-OWN D VILLAGE
AND Wa'
SPECIFY PP1nger
D. STREET ADDRESS 125 New Hambura Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 24 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Caroenter
B. TYPE OF INDUSTRY OR BUSINESS Local19
5. PLACE OF BIRTH DN~e. New York
(~rry.~We';~ NOT USA)
6. FATHER
A. NAME James Calvin Tomlins
B. COUNTRY OF BIRTH USA
7. MOTHER
ZIP 12537
DYES o"NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
10 / 18
MONTH DAY
30
13.B. DATE OF BIRTH
13. A. AGE
14. EMPLOYMENT
A. USUAL OCCUPATION Waitress
B. TYPE OF INDUSTRY OR BUSINESS Villi Borghese CMerlng
15. PLACE OF BIRTH Queens. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME George Weldon. Jr.
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME
A. MAIDEN NAME MAty Me AllndAn
B. COUNTRY OF BIRTH USA
1
GInA T-....no
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
18. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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) D DIVORCE (3) D ANNULMENT (2) DDEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE{S) ALIVE? DYES D 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
as to my right to enter into the marriage te.
21. SIGNATURE OF GROOM ~
D 1ST D D
D 2ND D D
D 3RD D D
D 4TH D D
plie! t at t e information 1 provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ ~ D~C: 7J..)~}d cdl_
USE CURRENrNAME
DATE 0912112004
authorized by New York Domestic
w
en
z
w
o
::;j
TIME
MONTH
YEAR
TE 09121
F811s NY 12590
STAT
27. TY~ OF CEREMONY
o i11' RELIGIOUS
9 D OTHER, SPECIFY
ZIP
AM
01 :52M
09
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 OCCURRED
A.STATE NEW YORK B. COUNTY~. 1?
C. LOCATION OF CEREMONY ., (
(C~ ONE AND SPECIFY)
,\/,CITY OF D TOWN OF D VILLAGE OF
rv>SPECIFY . /=3 (Q Q Q 0 f)
. . / 0 - If 05 (
ZIP
31. WITNESS TO CEREMONY
1 D CIVIL
29. OFFICIANT
NAME W.RINT)
NAME (PRINT)
SIGNATURE ~