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COUNTY Dl Jtchess
CITYITOWN WAppinger
~~~~~CRT 1 'ViS
~5~~J~R 1 'in
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas William Harman
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lara A Tompkins
~
1. A. FULL NAME
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
FIRST
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Harman
(OPTIONAL - SEE REVERSE) 129-52-0470
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. SO. Carolina B Richland
ISTAT~ (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Columbia
D. STREET ADDRESS 1012 Maxcy street
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 99
D SOCIAL SECURITY NUMBER 249-41-41
2 RESIDENCE A. ~AW)h Carolina B. l~Ls~land
c. CHECK ONE otCITY 0 TOWN 0 VILLAGE
~~~CIFY Columbia
D STREET ADDRESS 830 Columbia College Drivt> 29203
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? O~ES 0 NO
32
13.B. DATE OF BIRTH
29201
ZIP .,;
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
06 / 06 /1971
YEAR
3. A. AGE 31
4. EMPLOYMENT
A. USUAL OCCUPATION Editor
13. A. AGE
3B. DATE OF BIRTH
MONTH
DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Spnngdale elementary
15. PLACE OF BIRTH poughkeepsie, New YOrl<
(CITY, STATE/COUNTRY IF NOT USA)
a TYPE OF INDUSTRY OR BUSINESS Univ. Of So. Carolina
5. PLACE OF BIRTH Columbia. South Carolina
(CITY, STATEiCOUNIRY IF NOT USA)
6. FATHER
A. NAME .JHm~ Charlton Harman. Sr.
a COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Uane Sklnraer
a COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
Q 0
DEATb
16. FATHER
A. NAME Thomas Wade Tompkins
B. COUNTRY OF BIRTH USA
17. MOTHER
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A. MAIDEN NAME Patricia Ann Ortolano
a COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOOE CIVIL ANNUbMENT
DEATH
o
8. HOW DID LAST MARRIAGE END? 13) 0 DIVORCE
(3) 0 ANNULMENT
/ /
12) 0 DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
13) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSEIS) 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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that norlegal impediment exists
as to my right to enter Into the marriage state. , j) . _ ('J ~ _. ""f).
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ ~~ ~
23. A USE CURREN AME 10J30f2oo3
DATE
This license authorizes the marriage in New York State of the ide and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within 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
~
{ SEAL }
'-v-I
10
NAME (PRINT)
YEAR
TIME
MONTH
10:541
PM
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY ~
C. LOCATION OF CEREMONY
(C~CK ONE AND SPECIFY)
~ CITY OF ':)0 TOWN OF 0 VILLA~E OF
SPECIFY ~Ie
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~