187
co
o
to
N
.,...
_ w
~S
00
>-
~
Z ~
!z .
lllc :>
wO c(
IDO Q
9('0 w -
::>0) " IL
~ S IL
'" ...J.-
z.;:....
~~
!;(:J 0
1=0 ~
~u
l:!m
wo)
~O)
ii:C
~
::!
15O
r
u:
;::
a:
w
(,)
w
a:
w
:!:
~
'"
'"
w
a:
o
o
<(
~
B
w
0..
'"
, )"
,
'~...-
~~~ W
l;j~~ I-
~ffiz c(
~d~ 0
::!Cl5 u:
!Z~CI) _
~~~ I-
iEo'" a:
01-> W
wlllC5 0
b~"'
z::;~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Dennis 1= Milhnlm
MIDDLE CURRENT SURNAME
23. SUBSCRIBED AND SWORN TO B ORE ME 12/10/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New Yo above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies hin New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pu ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY[)1 ,tr.hp~~
CITYITOWNV\I CI ppinopr
~~J:k~1368
~5~'g~R18 7
1. A. FULL NAME
ARST
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE).
D. SOCIAL SECURITY NUMBER v61-74-8190
2. RESIDENCE A.N.A~prk B. ~~f::
C. CHECK ONE ~ CITY 0 TOWN 0 VILlAGE
AND
SPECIFY Beaco'1
D. STREET ADDRESS?O Angela Court ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE? ~ YES 0 NO
3. A. AGE29 3B. DATE OF BIRTH M&1 / ~Y / ~~3
4. EMPLOYMENT
A. USUAL OCCUPATION Systetr Arlmini~tr~tnr
B. TYPE OF INDUSTRY OR BUSINESS I R M
5. PLACE OF BIRTHMnllnt I(i!llnn Np-w V nrk
~IFNOTUSA)
6. FATHER
A. NAME Thomas Milholm
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Maureen Me Guire
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
o
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
a:
w
..
::E
:>
z
o
~
t;
W
It
li;
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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
w
en
z
w
o
::::i
r-^-.
{ SEAL }
'-v-'
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
f.)t;ltG
lk I ~ - c ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Corinn J. Powles
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE M i Iholm
(OPTIONAL - SEE REVERSE}., 10 72 8869
D. SOCIAL SECURITY NUMBER I - -
12. RESIDENCE ANew York 8.0rance
(STATE) (cou'f:trY)
C. CHECK ONE 0 CITY 0(] TOWN 0 VILlAGE
;~CII:yCornwall
D. STREETADDR~3 ,t'arris Lane ZIp12518
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/13 ;t980
DAY YEAR
E.
13. A. AG~??
14. EMPLOYMENT
A. USUAL occuPATloNAdministrative Assistant
B. TYPE OF INDUSTRY OR BUSINEssBoat-n-R V Warehouse
15. PLACE OF BIRTHGoshen. New York
(CITY, STATEICOUNTRY IF NOT USA)
13.B. DATE OF BIRTH
10
MONTH
16. FATHER
A. NAMEDonald Powles
B. COUNTRY OF BIRnU S A
17. MOTHER
A. MAIDEN NAME (";nnf::tance Davis
B. COUNTRY OF BIRnU S A
18. NUMBER OF THIS MARRIAGE 1
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
o 0
o 0
o 0
o 0
ga impediment eXists
22. SIGNATURE OF BRIDE ~
TIME
MONTH
NAME (PRINT)
--
SIGNATURE ~
MAILING ADDRESS
2002 02
08 2003
S
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
MONTH
YEAR
AM
12:52 PM 12
11
O;J.
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
lo4"lL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY UIl/f'P/
C. LOCATION OF CEREMONY
(CHECK ONE AND -SPECIFY)
o CITY OF c::vfc,WN OF 0 VILLAGE OF
SPECIFY 1Je..,) f)A-/ r v
29. OFFICIANT
NAME (PRINT)
26. SOLEMNIZATION OCCURRED
TIM AY Y AR
','Zo AM /l" II
V-OIJ~ O__.!;9r?-
TITLE
..-- ---
SIGNATURE ~ -
MAILING ADDRE~S .A f. . ""
2J jJ//I~~~1 ,)l/L#v-t:.
STREET CITYfTOWN
3D. WITNESS TO CEREMONY
-r-; 1. A. I (). Y -r~
NAME (PRINTl__.J.L' I '(/~.. t - pA - '
SIGNATURE~
DOH-98 (11/98)
DATE
NM I&rl, /l/7
7IJ,v;J h",>> C,l
,
I' -/'I-l) ~
It/?/
STATE
NAME (PRIN"
SIGNATURE ~ /: