158
]
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COUNTY ~
CITYfTOWN Wapp~
~5'J~fFi 1 ~
.r ~5~~l~R 1 sa
I-
Z
W
en
w
OJ
o
....
=>
o
:I:
en
z
o
~
a::
I-
en
a
w
a::
w
Cl
<(
a:
a::
<(
::.
IL
o
W
l;:
U
u::
;::
a::
w
u
w
a::
w
:I:
;::
en
w
w
a::
o
o
<(
>
IL
(3
W
"-
en
~:i:z
=>t:Q W
tii;::~ ~
::ffi~ <(
3d~ 0
~~g u:
z-
~~~ t=
Itow a:
01-> W
w~<5 0
b~~
Z:J~
II
)
q" 1 ST 0 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
lef that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ F'. · ^ ^ -.A. ...... ~ OQ~
~RENTNAME
23. SUBSCRIBED AND SWORN TO B
SIGNATURE OF TOWN OR CITY ERK ~ DATE
This license authorizes the marriage in of the bride and groom named above by any person authorized by New or omestic
Relations Law ~11 to perform marriage ceremonies withi ew 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
1. A. FULL NAME
MIDJL,mes SmiMtRENT SURNAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
Q93.. 36-8646
2. RESIDENCE A. '~)Yor.k B. ~888
C. X~6CK ONE 0 CITY o;rOWN 0 VILLAGE
SPECIFY i:ast Fishkill
D. STREET ADDRESS 79 Lake Welton Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
ZIP 12580
o YES D,II NO
3. A. AGE Sf
4. EMPLOYMENT
A. USUAL OCCUPATION Dmrer
B. TYPE OF INDUSTRY OR BUSINESS UPS
5. PLACE OF BIRTH ~A~~"&: York
6. FATHER
3B. DATE OF BIRTH
M
A. NAME Edward Smith
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME MIry &:Jeet
B. COUNTRY OF BIRTH U S .'\
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) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? fUi./... / -...
MONTH V9 DA'iI'"' 'iiUiIIIiJ'l
D. ARE ANY FORMER SPOUSE(S) ALIVE? Q.lI"ES 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
06116'12001 ~.. tJe\'" York
o
o
II:
W
lD
:;
:0
Z
o
z
'"
t;;
W
II:
?-
m
21. SIGNATURE OF GROOM ~
W
en
z
W
o
::i
~
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~ -'
MAILING ADDRESS
~
r
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A. FULL NAME
~8 M. ~ENT SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE D. ith
(OPTIONAL - SEE REVERSE) ~
D. SOCIAL SECURITY NUMBER 073-5&-7&19
12. RESIDENCE A. ....?faflc 8. QutctJess
c. X~6CK ONE 0 CITY O,jPWN 0 VILLAGE
SPECIFY \,\lappinger
D. STREET ADDRESS 109 1888 Route 9 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~O
MoDI /:iII ~9JO
13. A. AGE 3J
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Mecical Biller
B. TYPE OF INDUSTRY OR BUSINESS Otltd\ess Surgical Assoc.
15. PLACE OF BIRTH No..~\lMew York
16. FATHER
A. NAME Kenneth Paul Jams
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Michelle L.ouI5e 6ttIby
B. COUNTRY OF BIRTH U a A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIV!L ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
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
ZIP
TIME
MONTH
YEAR
YEAR
TE 1210312OO3
ST ATE
~~~R~~~Ri~~ ~~O~~~N~zEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR O~ RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND AM
PLACE INDICATED. J;"f3oPJ!l / - 3- oy- 90 OTHER,SPECIFY
~~,J:~~~~~T W.JJ I A M. A 01JJfJ O' TITLE /Vi, AI (t T p R..
SIGNATURE ~ 'f4.{~ a iJ,J-wz,f DATE fl~,.8 () 7'
MAILING ADDRESS IT:' J--
f)~ q I IBT j).J- PJII'pIJ.,fl7(.j He tV Y IJfC"
STREET CITYfT6WN STATE
30. WITNESS TO C ,REMONY
NAME (PRINT)
SIGNATURE ~
DOH-9S (11/98)
A.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY V ILL II 80 R. GHE '3'1:
\.V !tPP/IVGER
NAME (PRINT)
SIGNATURE ~
31. WITNESS TO C