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COUNTY ~
CITY/TOWN Wapp~
~~J:k~~T 1 ~
~~~~J~R 7Q
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.~ u ~0lL
MIDDLI! CURA!NT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Hallll~ lev.aA~ SURNAME
~
1. A. FUll NAME
11. A. FUll NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~m::,.'Z~~~t~~e~~SE)H8Ring
O. SOCIAL SECURITY NUMBER 014-72-5666
12. RESIDENCEA. N-.1ar:k B. ~~B
C. CHECK ONE D CITY o,rOWN D VILLAGE
AND '.
SPECIFY FlShkill
D. STREET ADDRESS 6 Chatham Court
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
O. SOCIAL SECURITY NUMBER Q69.66.9521
2. RESIDENCE A. ~E~Ork B. ~ell
C. CHECK ONE D CITY IJ"TOWN D VILLAGE
AND ,..,_.
SPECIFY V-.pprvr
D. STREET ADDRESS 5 W,~ Ollve 11 C
ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
MO'tQ / (2 -"1_
12590
YES [JII' NO
/ y1i79
ZIP
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E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? D
3. A. AGE 25 3B. DATE OF BIRTH n? n?
MOilll'l!F / I'Jl!IF
4. EMPLOYMENT
A. USUAL OCCUPATION Pnlir.P- ()ffir.P-r
B. TYPE OF INDUSTRY OR BUSINESS CIty Of Poughkeepsie
5. PLACE OF BIRTH DN .l'IhlMArl&la I\Iaw V ork
~~
6. FATHER
A. NAME I=ranr.iR. ThnmSIR WArring, Sr
B. COUNTRY OF BIRTH USA
A. NAME SlaNey JohA UwaAda\Mlki, Jr.
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Susln Cleel\"l8ter
B. COUNlTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
13. A. AGE 23
14. EMPLOYMENT
A. USUAL OCCUPATION ReceptiDAiat
B. TYPE OF INDUSTRY OR BUSINESS Dr.':JeRldc
15. PLACE OF BIRTH ~~~oMefl Vork
16. FATHER
13.B. DATE OF BIRTH
7. MOTHER
A. MAIDEN NAME JacquelyR HileR SagrOlky
B. COUNTRY OF BIRTH II 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
o
(2) D DEATH
o
o
o
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
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
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
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1ST D D 1ST D D
2ND D D 2ND D D
3RD D D 3RD D D
~ D D ~ D D
I, being duly sworn. depose and say, that to the best of my know edge and belief that the information provided is true and t at I declare that no legal impediment exists
as to my right to enter into the marria state. ..:.LA? 1
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ ~ ~ L_..../!../
USE CUR~TliiAME
23. ~::;..fT~~~Do~N.fo~~O~: 6t~B CLE~~E DATE
This license authorizes the marriage in New York any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL}
'-v-I
NAME (PRINT)
MONTH
DAY
YEAR
YEAR
TIME
ATE 0l/16t2004
11:21~~
ZIP
MONTH
17
09
14 2004
07
AT
27. TYPE OF CEREMONY
oK RELIGIOUS
9 D OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1 D CIVil
28. PLACE WHERE MARRIAGE OCCURREDf)
A. STATE NEW YORK B. COUNTY _"..1c.I.t fJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF j!. TOWN OF D VILLAGE OF
SPECIFY F.-J' I:"
os;> '-I fJ
(le> (J&t.-r (. WILt"lW
SIGNATURE~ ~ ~ ~~
MAILING ADDRESS
1~..3 =r-a cA rr- f"+
STREET CITY/TOWN
30. WITNESS TO CEREMONY
29. OFFICIANT
NAME (PRINT)
TITLE C~ f,c:.. f"uf
~-J. 'f-DI/
Fis" ~,II AI Y ("';-2-
STATE ZIP
31. WITNESS TO CEREMONY
DATE
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~
e (2./1.16-
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