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J 4 COUNTY Dutchess
CITYfTOWN Wappinaer
1368
55
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Wilfred Arthur Jones
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
DISTRICT
NUMBER
REGISTER
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Geraline Eugene
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 362-98-8930
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE).......tI... (eoUNTY)
C. CHECK ONE 0 CITY U"TOWN 0 VILLAGE
~~~CIFY Wappinaer
D. STREET ADDRESS 27 F Surrv lane
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Eugene - Jones
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. Nm York B. ~~ess
~A~ ( )
C. CHECK ONE 0 CITY 0 lIfOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 27 F Suny lane
ZIP 12590
o YES cr'NO
ZIP 12590
YES 0"1ID
/1ilB
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 39 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Manufacturer
B. TYPE OF INDUSTRY OR BUSINESS Spectral System
5. PLACE OF BIRTH -.Jamaica. West Indies
(CITY, STATElCOONTRY IF NOT USA)
6. FATHER
A. NAME Everest Jones
B. COUNTRY OF BIRTH Jamaica
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE '4 13.B. DATE OF BIRTH 05 / 1~
MONTH DA"
14. EMPLOYMENT
A. USUAL OCCUPATION Un - Employed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Sf luci~.Jl'Iest Indie~
(CITY, STATElCOuN I HY IF NOT USA)
16. FATHER
A. NAME Cyril Eugene
B. COUNTRY OF BIRTH West Indies
17. MOTHER
A. MAIDEN NAME Mary Joy
B. COUNTRY OF BIRTH West Indies
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
(2) 0 DEATH
7. MOTHER
A. MAIDEN NAME HerJP-t Br~
B. COUNTRY OF BIRTH .lamRica West Indies
8. NUMBER OF THIS MARRIAGE 2 .
..
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 n
B. HOW DID LAST MARRIAGE END? (3) o'fi,VORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? n4/:JR /
MONTH J DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? O"'rES 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
f14/:JR/:Jnn~ POlIghlrlP.l6p!ll'e, Np'w York 0.... 1ST
o 2ND
o 3RD
o 4TH
be Ie that the InformatiDn I provl ed is true and t at
o 0
o 0
o 0
o 0
o legal impediment exists
DEATH
n
(2) 0 DEATH
:Jnn~
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY
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
YEAR
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W
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21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO 8EFORE .
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York
Relations Law ~11 to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pur ose of a second Dr subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
n!;IO!;/:Jnn~
by New York Domestic
~
{ SEAL }
'-v-'
TIME
MONTH
YEAR
MONTH
YEAR
AM
01 :2.f'M
05
06
200
07
04 2003
l~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )q;'TOWN OF 0 VILLAGE OF
SPECIF'A 2)~?i Yjer
NAME (PRINT)
SIGNATURE ~