190
'I
,-;.:..
co
<D
0>
N
(If
C
e w
co ....
<(
0 ....
en
..c
ol-'
::J
0
C/)
.... ....
ml'i >
:::.Q <(
c>. C
...JetS w -
a- co LL
~ ~I.L
z-~<(
00) z
~2: ~
a:'" I:::
t;Oi;
~o
w'"
ClO
:!O)
~c
~
11.
o .
~
<(
~
~
a:(Y)
w
()
w
a:
w
I
~
(/)
(/)
w
a:
c
c
<(
>
11.
C3
W
0-
(/)
z Z
~ ~ w
:l! ;:s ....
.... Z <(
!!l ai 0
::; 5 u:
!z (/) ....-
<( 11.
~ 0 a:
t) ~ W
W c 0
b "'
z ;;::
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
BriaD !;<.fith Fergllson
10 CURRENT SURNAME
COUNTYnllt~hp~~
CITYfTOWN \A/;=trrinopr
~m~~~~T'136.g
~G~~l~R 19n
1. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl..
O. SOCIAL SECURITY NUMBER -u77 -54-9496
2. RESIDENCE A. SoMt~parolina B. C-'~~'JWillp
C. CHECK ONE ,,{] CITY 0 TOWN 0 VIllAGE
AND
SPECIFY T aylors
O. STREETADDRESS~~4 N Pinp.~rnft nrive ZIP ?flRB?
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? o!i YES 0 NO
~ /~ly /4al3
3. A. AGE29
4. EMPLOYMENT
A. USUAL OCCUPATION Shipper & Recei\ler
B. TYPE OF INDUSTRY OR BUSINESS Sllper Dllr~r Pllblir:::Itinn~
5. PLACE OF BIRTHPre'~~ ~~I York
( , /Ii FNO A)
6. FATHER
3B. DATE OF BIRTH
A. NAME Donald 'Milliam Ferguson
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Sandra Ruth Stocker
B. COUNTRY OF BIRTH U S 11
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
(2) 0 DEATH
o
o
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
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)
JR1l[
I~' 3/ 'tJ1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
A"/~nn Ann Pe~nra
J MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE r=pro"~nn
(OPTIONAL - SEE REVERSE)
O. SOCIAL SECURITY NUMBER nq 1-7 4-7qq~
12. RESIDENCE A...~nllL~f::lrnlin::l B. G~~fu~iIIA
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND
SPECIFY T aylnr~
D. STREET ADDRESs33~ N Pinecroft Drive zIP29687
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE21 13.B. DATE OF BIRTH ~~TH /2~y /f'9y~1
14. EMPLOYMENT
A. USUAL OCCUPATION Nllr~p T p~h
B. TYPE OF INDUSTRY OR BUSINESS Greenville Memorial
15. PLACE OF BIRTHPnrt ~hp-!=;tp-r' NAw"Vnrk
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME,Anthnny pp~nr::l
B. COUNTRY OF BIRTH J S A
17. MOTHER
A. MAIDEN NAME R1lth Ann Reynolds
B. COUNTRY OF BIRTH I S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
n
(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
a:
w
ID
::;
::>
z
c
z
<(
....
w
W
II:
....
<J)
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
and belief that the information
o 0
o 0
o 0
o 0
that no legal impediment exists
23. SUBSCRIBED AND SWORN TO B RE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marri e in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within 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
21. SIGNATURE OF GROOM .:
w
en
z
w
o
::::i
~
{ SEAL }
'-v-I
SIGNATURE ~
MAILING ADD 55
? '
S
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o;>cr RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Du.1C-!-h :os:
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF i;J TOWN OF 0 VILLAGE OF
TITLE
NAME (PRINT)
SIGNATURE ~
DOH-9B (11198)
DATE
12/18/2002
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
AM
01 :29 PM 12
16 2003
19
2002 02
SPECIFY t;. 4- Ss} ~ 6/1 JC 1 (.... L
/2..5"33
ZIP
". w,,,m wc",oo", ~
NAME (PRINT) ~o.. ~lAn ..., ()
SIGNATURE ~ "11A..l.l.hrt