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COUNTynlltr~hp<::c:;
CITYrTOWN 'AI 8ppinOPr
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~5~I~J~R 17 8
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
l::JE'rbe.'rt A .~cott
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
$J/lt
iJ-Jp.-t1
L D SUPPLEMENTAL FILE
FROM THE BRIDE
r.h;::JrIAne C Morris
MIDDLE CURRENT SURNAME
1 A. FU LL NAME
11. A. FULL NAME
FIRST
FIRST
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT F r:=t n I<s
c. SURNAME AFTER MARRIAGE ~r.ntt
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 f11-4n-77?7
12. RESIDENCE A.I\IV B. IJIItr.hess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY f!l'l TOWN 0 VILLAGE
AND '^/ .
SPECIFY :=trrllnoer
D. STREET AODREss1 0 Harbor Hill Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATEO VILLAGE? 0 YES ~ NO
13. A. AGE53 13.B. DATE OF BIRTH 11 /26 /'f948
MbNTH DAY YEAR
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 063- 38-9490
2 RESIDENCE A. N ';(TATE) B. D!rlJ5iJ:M'ss
c. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \^ .
SPECIFY lapplnger
o STREET ADDRESS 10 Hflrhnr Hill Rn:=trJ ZIP 1)~qn
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"l"J NO
M~ / ~~ /1a-17
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3. A. AGE55
4. EMPLOYMENT
A. USUAL OCCUPATION ChemisVRetired
14. EMPLOYMENT
A. USUAL OCCUPATIONnis:=thIArJ
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH~11t Pleasant,. Pennsylvania
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEr.h:=trlps Fr:=tnks
B. COUNTRY OF BIRT~ J S A
17. MOTHER
A. MAIDEN NAME Grace Irene Mc Ollley
B. COUNTRY OF BIRTH J ~ A
18. NUMBER OF THIS MARRIAGE ~
3B. DATE OF BIRTH
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH 8r\1vny I\lpw Y nrk
(CI , Sl'A TE/COUNTRY IF NOT USA)
6. FATHER
A NAME Herbert Anderson Scott
B. COUNTRY OF BIRTH I I ~ A
7. MOTHER
A MAIDEN NAME Estelle ,A.damac
B. COUNTRY OF BIRTH U S Ii
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHiCH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
On? n
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 11 / '/5 / 199? c. DATE LAST MARRIAGE ENDED? n~ / 1 n / Hl7f1
MONTH DA'i' YEAR MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? i'!1'YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF OECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 11125/1992 Poughk@@psi@, N€N/ York ~ 0 1ST 07/15/1969 \J\/estmnrplClrtrl r.o, PAD
2ND 0 0 2ND O~/1n/1!=l7f1 Wpstmnrpl;:mrl Co P A t1
3RD 0 0 3RD 0
4TH 0 0 4TH
I, being duly sworn, depose and say, that the best of my knowledge and lief that the information I provided is true
as to my right to enter into the marria S te.
1
o
21. SiGNATURE OF GROOM ~
. SIGNATURE OF BRIDE ~
.
DATE 11/13/2002
by New York Domestic
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23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage 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
~
{ SEAL }
'-y-I
MONTH
YEAR
YEAR
TIME
MONTH
ZIP
AM
03:00 PM 11
14
200.:. 01
12 2003
1~L
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT;;J)a.1C1I9h
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF 0 TOWN OF ~VILLAGE~ JL
SPECIFY lIUA-AOJ meg ~
NAME (PRINT)
SIGNATURE ~
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