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.._"._.~-'''.~-_.'-'~---- .~.._~.. ----_.-----'-- ------
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STATE FIl.E].IUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutche5$
jlo. CITYrrO~N WWnger
~~J:~c: 1368
~5~~l~R 1.t9
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael F Walker
MIDDLE CURRENT SURNAME
FIRST
I
I
/
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.Iennifer I Me: ChiIV_
MIDDLE CURR~-SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mr.: Clay
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER Cf17 "r.J_ff1R~
12. RESIDENCE A. ~rnrk' B. ---W~
C. CHECK ONE 0 CITY 0 I#foWN 0 VilLAGE
AND l.M...
SPECIFY VVi'llppnger
D. STREET ADDRESS 1~ Old state Road ZIP 125M
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~O
13. A. AGE 31 13.B. DATE OF BIRTH MOAil /?r.r /1$1I2
14. EMPLOYMENIT
A. USUAL OCCUPATION Artm~~nr M~Ant
B. TYPE OF INDUSTRY OR BUSINESS I-apan AdvAnte~
15.PLACEOFBIRTH (r~JrYort
16. FATHER
A. NAME RllgP-I" Alan Me: Clay
B. COUNlTRY OF BIRTH II S A
17. MOTHER
A. MAIDEN NAME Arlene FlOfIRCI \l\4nt1r
B. COUNlTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 12~ ~_ ~1 M
D. SDCIALSECURITYNUM8ER _~ L__
2. RESIDENCE A. New Vork B. nutchfl!!l&
~) (COUNTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND Wa"
SPECIFY ppnger
D. STREET ADDRESS 14 Old state Road
ZIP 12590
DYES D"'NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 3B 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Ter.hnidliln
B. TYPE OF INDUSTRY OR BUSINESS I\'nv North 1:"....
5. PLACE OF BIRTH (~~"T"" Vtd'k
6. FATHER
A. NAME Arthur .lameR Walker
B. COUNlTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Helen Made Fox
B. COUNlTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENIT
o 0
DEATH
DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF ElECREE 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
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
ediment exists
o 1ST
o 2ND
o 3RD
o 4TH
nd belief that the information I provided is tru
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
1nn7nt1n3
by New York Domestic
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~.
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi 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 }
'-y-I
YEAR
MONTH
YEAR
NAME (PRINT)
SIGNATURE ~--
MAILING AD~RESS
TIME
MONTH
08. "4+M
. "PM
10
28
12
28 2003
ZIP
1~L
ATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 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.
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. cou~~iiZI{tJJ;
C. LOCATION OF CEREMONY
(CHECK ONE AND ~CIFY)
o CITY OF B"'TOWN OF 0 VILLAGE OF
SPECIFY f1/5f P,' sH K, 'Lt..
NAME (PRINT) '>.t
SIGNATURE ~ ...
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ~c..I-( 3'. WIJt.frER
SIGNATURE~ ~~
nnL.LOA ,....lOa\