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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jeremy Noel Carman
MIDDLE CURRENT SURNAME
COUNTY' Dutchess
CITYfTOWN W&pI:lInger
DISTRICT 1368
NUMBER
~~~I~J~R 79
1. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 303-04-0734
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. Tennessee B. Hamilton
(STAT~ (COUNTY)
C. CHECK ONE [J"' CITY 0 TOWN 0 VILLAGE
~~~CIFY Chatta~
D. STREET ADDRESS 907 uth Beech street
ZIP 37404
D~ES 0 NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 22 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Youth Pastor
B. TYPE OF INDUSTRY OR BUSINESS Community Baptist Church
5. PLACE OF BIRTH Hammond. Indene
(CITY. STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME \Mlliam R. Carman Jr.
B. COUNTRY OF BIRTH U S A
7. MOTHER
Deborah L Hendon
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
A. MAIDEN NAME
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE ENO? (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 FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jacquelyn K. A Smith
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Carman
(OPTIONAL. SEE REVERSE) 094-72-0256
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECK ONE 0 CITY 0 ""TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 131 Cider Mill Loop ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D'lfNO
13. A. AGE 22 13.B. DATE OF BIRTH 12 / 17 /1980
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Te~:rllemple UnIv.
15. PLACE OF BIRTH Poughkeepsie, 0
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Ronald Morton Smith
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Evangelyn Kay Gardner
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
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
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
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the in ormation 1 provided is true and that I declare that no legal impedilTlflnt exists
as to my right to enter into the marria sta '
21. SIGNATURE OF GROOM ~
w
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. SIGNATURE OF BRIDE ~
by New York Domestic
for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
06124
NY 12590
TIME
YEAR
MONTH
ZIP
AM
03:0IM
08
SA
27. TYPE OF CEREMONY
o IV" 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 INOICATEO. (0 cr8 03
29. OFFICIANT II) I . II , _ ',.1 ~I
NAME (PRINT) ~~ ~~ I~ Ja. Y\ '^ Vf6\ W\.\of 1\
SIGNATURE ~ ~~ ~/{fi"~
MAILING ADDRESS
"Lj f! ('CO<:r-t sJ.. E? OVt3h ~f7;..O
STREET CITYfTOWN
30. WITNESS TO CERrMONY
NAME (PRINT) .J I
SIGNATURE ~
TITLE
DATE
nn""~QA 1111OA\
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY (l...J.c ~(f
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
tel CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY fbVj h h.l1.g2 fie
NAME (PRINT)
SIGNATURE ~