122
]
I--
Z
UJ
(/)
UJ
CD
o
...J
;:J
o
I
(/)
Z
o
~
a:
I--
(/)
(3
UJ
a:
W
<!l
'"
a:
a:
'"
:;;
u.
o
W
t;:
()
u::
;::
a:
UJ
()
W
a:
W
I
;;
(/)
(/)
W
a:
o
o
'"
>
u.
i3
W
"-
rn
~:i::i
~t:Q
1--;;1--
~~~
I--WZ
rn...J:;;
;:J()W
:!C90
I-Z(/)
Z-
~~~
tta(/)
01-->
Uj~(3
b~'"
Z:J~
COUNTY Dutch..
CITYiTOWN V".pplnger
~~J:~CRT 1_
~~~~J~R 122
::s I A I t: Ut" Nt:VV YUH~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J&ndP't P8Fket~RNAME
FIRST
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. FULL NAME
11. A. FULL NAME
RwIm M. Tett.erfQA,NT SURNAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
O. SOCIAL SECURITY NUMBER .
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE .13-.....1
(OPTIONAL - SEE REVERSE)~e
D. SOCIAL SECURITY NUMBER OGJ.. 74<6749
12. RESIDENCE A. _..au.ells B.~
C. X~6CK ONE q,CITY 0 TOWN 0 VILLAGE
SPECIFY Everett
D. STREET ADDRESS i2 PeIrce Avet"lue}f:t 1 ZIP 02149
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? q,; YES 0 NO
13. A. AGE "Zl 13.B. DATE OF BIRTH M~ / 0& ~9J1
14. EMPLOYMENT
530-06-1837
2 RESIDENCE A. h"gaehusetls B. ~esex
c. X~6CK ONE I:;j,J CITY 0 TOWN 0 VILLAGE
SPECIFY E~Jerelt
D. STREET ADDRESS 72 Pelfoe Avenue,'\IX. 1 ZIP 02149
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? q;YES 0 NO
Mom / ~7 / yUITl
3. A. AGE 2G
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Editor
B. TYPE OF INDUSTRY OR BUSINESS Self Empleyed
5. PLACE OF BIRTH ~JJ...,,~_.
6. FATHER
A. USUAL OCCUPATION Sign Language Interpreter
B. TYPE OF INDUSTRY OR BUSINESS Mess. }esoc,. Of The Deaf
15. PLACE OF BIRTH ~.e.oNew York
16. FATHER
.. I-
:>
c:(
c
u:::
;iLL
c:(
A. NAME John Edward Tetterton
B. COUNTRY OF BIRTH USA
17. MOTHER
A. NAME RiGhar-d lIIlrJr8AGe Seule
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dar;t Ann Hogan
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. MAIDEN NAME Penelope Chapin Parker
B. COUNTRY OF BIRTH U S ^
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
o
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
2D. IF PElEVIOUSLY 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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and
as to my right to enter into the m
21.
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
e and belief that the information I provided is tr
o
o
o
a:
w
'"
::;;
::>
Z
a
z
'"
I-
W
W
a:
I-
en
w
en
z
w
()
:J
23. SUBSCRIBED AND SWORN T FORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S e 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
York Domesti!
~
{ SEAL}
'-v-'
NAME (PRINT)
YEAR
MONTH
YEAF
TIME
MONTH
09lO8l2OO3
AM
09:15pM
09
09
10 CIVIL
11 07 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY IA/ster
ZIP
, ATE
27. TYJE OF CEREMONY
o IV" RELIGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF
SPECIFY ~
o VILLAGE OF
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMEO ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TITLE
M"'JIf7-re~
1(7//'Z_/6$
" ,
I Z-t-ol
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ~O bert- SovJ~
SIGNATURE~~ ~