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C~NTY r'hJtd\MS
CITYITOWN W4'ppI~
~~J~kcFi 1368
~5~~J~R 102
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~ond J ~SURNAME
I""
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Tina M. Me VfN
MIDDLE
1. A. FULL NAME
1 1. A. FULL NAME
CURRENT SURNAME
FIRST
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~D AA_1QQ1
2. RESIDENCEA.~)ynrtr B. ~~
C. CHECK ONE 0 CITY [JilI"rOWN 0 VILLAGE
~~~CIFY I=iRhIriII
D. STREET ADDRESS 12 Field Court Unit 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Cocty
(OPTIONAL - SEE REVERSE) 1~-"""" A323
0: SOCIAL SECURITY NUMBER .e.J- I .e._
12. RESIDENCE A. Nf!IN York B. Dutchess
~E) (COUNTY)
C. CHECK ONE 0 CITY D~OWN 0 VILLAGE
~~~CIFY FlShkill
D. STREET ADDRESS 12 Field Court Unit 0 ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:JI NO
13. A. AGE ?R 13.B. DATE OF BIRTH 05 / 16 /1915
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE]6 3B. DATE OF BIRTH
4. EMPLOYMENT
ZIP 12524
DYES alNO
M
14. EMPLOYMENT
A. USUAL OCCUPATION Musie Teacher
B. TYPE OF INDUSTRY OR BUSINESS Self - EmDlovecl
15. PLACE OF BIRTH N_e. New York
(CITY, S TElCOUN Y IF NOT USA)
16. FATHER
A. NAME Edward Robert Me Vev
B. COUNTRY OF BIRTH USA
A. USUAL OCCUPATION Merr.hllnd!Ie foIancler
B. TYPE OF INDUSTRY OR BUSINESS G.p Inc.
5. PLACE OF BIRTH ~. f\Ia\AI York
~~N~
6. FATHER
A. NAME ~~mond .1.meR C""ody
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Miry Ann CZlnke
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
a 0
17. MOTHER
A. MAIDEN NAME ~rAC8 ~rotkQpp
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
(2) 0 DEATH
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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 0 0
2ND 0 0
3RD 0 0
~ 0 0
hat the in ormation provided IS true and that I declare that no legal impediment exists
22. GNATURE OF BRIDE ~ - J.~ [)..A . LA1r~
' USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE E ft"7131
SIGNATURE OF TOWN OR CITY CLERK ~ DATE VI,
This license authorizes the marriage of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within 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 ~ERIOD BEGINS
~
{ SEAL }
'-.-'
TIME
MONTH
YEAR
AM
12:13M
08
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 OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE A7 SPECIFY)
o CITY OF~ TOWN OF 0 VILLAGE OF
SPECIFY ~~
29. OFFICIANT
NAME (PRINT)
~"
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~