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079 J .... z w rn w al o ..J ::J o :I: rn Z o ~ cr .... rn a w cr w Cl .. a: cr .. ::; U- o w .... .. () u: >= cr w () w cr w :I: ;:: rn rn w cr o o .. > u- 13 w Q. rn II: W III :; ::> z o z .. .... w W II: .... III ~~~ W ....;::.... ~ ll!~~ _ ....wz .... ~d~ 0 ~~g u:: z- - ~~~ I- lEolll a: 0....> W w~C5 0 "'mU'l ~~h 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 en z w o :J . 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 ~