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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State 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 urpose of a second or subsequent ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY ~
CITYrrOWN Wllpplng.er
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~~~\mR 35
1. A. FULL NAME
,IAm~ S Innelil&.- .
MIDDLE . 'cuRRENT SURNAME
FIRST
11.
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCiAl SECURITY NUMBER 091-62..4712
2. RESIDENCEA.__IYork B. ~
C. CHECK ONE 0 CITY !:],frOWN 0 VILlAGE
~CIFY PnlV'~e
D. STREET ADDRESS 3 Essex Road ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES CiI' NO
3B. DATE OF BIRTH ~ / &Ii / JiB1
5. PLACE OF BIRTH
6. FATHER
A. NAME .Jllm. Inness
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAlDEN NAME Deborah Sye Gillespie
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) MIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08/?7 / o'Iaan
MONTH . own- ~
D. ARE ANY FORMER SPOUSE(S) ALI~E? 0 YES (]lfIo
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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O8I27J1980 PoughkMpllel Ne\.JVoFk 0
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21. SIGNATURE OF GROOM ~
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{ SEAL }
'-v-I
NAME (PRINT)
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Yi
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
. 11. A. FULL.NAME
M~I C. IilU~RRENT SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~JN~~~t~~O~~SE) InnBBB
D. SOCIAL SECURITY NUMBER 2&0-19-1632
12. RESIDENCE A. N-.' ,Yark B. n. "Ml-B
~TE) \U~N'I"i'l""""
C. ~~5CK ONE 0 CITY OIliOWN 0 VILLAGE
SPECIFY Poughke8pBie
D. STREET ADDRESS 3 e.. Road ZIP 1:l801
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~NO
Mc01: / fJB ~~
13. A. AGE 42
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION FlaaRAg IRBtaIler
B. TYPE OF INDUSTRY OR BUSINESS J & S IFldaIleFS
15. PLACE OF BIRTH ~'a~1
,c " A)
16. FATHER
A. NAME RadeRdc '.AlcJadrCIW IiluGk
B. COUNTRY OF BIRTH U S ^
17. MOTHER
A. MAIDEN NAME Margeret Ruth Payne
B. COUNTRY OF BIRTH U S /to
lB. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
2 0 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 05 / 001 / 2001
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~S 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
[)"t'
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07/1811987 Auguste, Qeor;Ia
0510112001 Augusta, OeBrgia
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TIME
MONTH
YEAR
04
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
, A
27. TYPE OF CEREMONY
o QKRELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
06 22 2004
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY(j}J1t~5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF j& TOWN OF 0 VILLAGf OF
SPECIFY . ~mepsle.
29. OFFICIANT
NAME (PRINT)
TITLE
NAME (PRINT)
SIGNATURE ~
DOH.9B (11/98)
24
f~~&
~/-o+
NAME (PRINT)
SIGNATURE ~