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174 "- N ~ 0 fD (""~ ..- 3- l...- .... :):. W ~:- f- <( .- f- iJ,l UJ ....,. "'- iJ) 1ij a... ~i,i) wi:l/ ~ iliC 00;, ..J::; LU - 50 '" u. vn:.ju. z ~oCt QiJi ~ i:3 g f-l:: ~ ~iJ) 0 @",:-- c:.;r- w -. W 0:0 ~g :2> 1St: ~ f- <c...- ~D i= c: w o w c: w I ;; :n :n .1J J: :> :> <( >- .... :5 JJ 1. Il a: w In ::; ::> z Cl Z <( f- W W a: f- UJ :i::i ~~ W ",;:j I- ffiZ oCt d15 () ~8 u: 5LL -I- ~O a: i2~ w ~~ () ~"' ~~ STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM i an D. Flewelling nut...h"""'S COUNTt" . u......." CITY/TOWl:.~PPlnger DISTRIcT. ,I-. (. NUMBER' - v , REGISTEFij 74 NUMBER 1. A. FULL NAME FIRST MIDDLE CURRENT SURNAME B BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL. SEE REVERS1{l}02-5t3-4 '12'1 D SOCIAL SECURITY NUMBER 2 RESIDENCE ANew York B Dutchess (STATE) '" (COUNTY) C. CHECK ONE Q CITY 0 TOWN 0 VILLAGE ~~~CIFY poUqnKeepsle ~'\ InWOOO Avenue !ZeOl D. STREET ADDRESS ZIP E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? . 69 3. A. AG~2 3B. DATE OF BIRTH 12 MONTH 4. EMPLOYMENT A. USUAL OCCUPATION Carpenter B. TYPE OF INDUSTRY OR BUSI~ssKey li1leiH):!'S 5. PLACE OF BIRTJ':!anover, ew Hampstllre (CITY, STATE/COUNTRY IF NOT USA) l- S; oCt Q 6. FATHER A. NAME .Joe! Flewelling B. COUNTRY OF BIRTH U ~ A 7. MOTHER I^<'ef'l'~;n~ T~~.. A. MAIDEN NAME ........." ",I II C; I all B. COUNTRY OF BIRTH USA B. NUMBER OF THIS MARRIAGE '1 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVBRCE CIVIL A1)'ULMENT D1tTH u B. HOW DID LAST MARRiAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / (2) 0 DEATH 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 ONL Y) 1!-/~~t1;? I 4JJtt L 0 SUPPLEMENTAL FILE FROr-a TH~ BHID~, " c..linSdne f\1l, raehy ~ 11. A. FULL NAME FIRST MIDDLE CURRENT SURNAME B. BIRTH NAME (MAIDEN NAME).lEiDIFFERI'J'lT r ewelllno C. SURNAME AFTER MARRIAGE - - -'~ .. (OPTIONAL. SEE REVERSeOlIJ-Ob-2.,)!'.:.0' D SOCIAL SEC~RITY NU)vlBE~ (' I ' i\tew Y 01'1< Ju.cness 12. RESIDENCE A. B. (STATE) ., (COUNTY) C. ~~6CK ~ou9~e~1~sie TOWN 0 VILLAGE SPECIFY Sol ImiVood A v ei IUC D. STREET ADDRESS ZIP E. IS RE.SI~NCE WITHIN LIMITS OF CITY OR INCORPORATlj~LLAGE? 112 0 13. A. AGE,,) 13,B. DATE OF BiRTH L . MONTH DAY 14, EMPLOYMENT Ph' ! Th . t . YSCla . eraplS. A. USUAL OCCUPATION ;::,epalilllelit Of'v\steran B. TYPE OF INDI.liTRY OF BLJS1I\IE:SSi.: :::l . oronx. NeW T OIl\. 15. PLACE OF BIRTH I (CITY. STATE/COUNTRY IF NOT USA) 16. FATHER I h R' II A NAME'- O. ,n ole.y . USA B. COUNTRY OF BIRTH '12601 .. YTJflONO YEAR 17. MOTHER . Evel"n Eisele A. MAIDEN NAME Y U:::;A B. COUNTRY OF BIRTH 1 1B. NUMBER OF THIS MARRIAGE 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY D'tfRCE CIVIL A~ULMENT D~TH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / (2) 0 DEATH 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 o o 1ST 2ND 3RD 4TH I, being duly sworn, depose and say, that to the best of m as to my right to enter into the marr~e state. 21. SIGNATUREOFGROOM~ ~ o 0 1ST o 0 2ND o 0 3RD o 0 4TH edge and belief that the information I provided is tru 23. SUBSCRIBED AND SWORN TO BEFORE ME SIGNATURE OF TOWN OR CITY CLERK ~ This license authorizes the marriage in New York Relations Law ~11 to perform marriage ceremonies wi In 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 CLI;RK 25. A. SOLEMNIZATION PERIOD BEGINS } NAME (PRINT) Glons { 10/30/2002 TIME MONTH YEAR SEAL SIGNATURE DATE '-.y-I M~(Mr8 .rfuush Rd,r Falls, NY 12590 02:00 ~~ 10 31 200 STREET' ZIP I CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF THE PER. SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND PLACE INDICATED w C/) z w () :i 22. SIGNATURE OF BRIDE ~ by New York Domestic MONTH YEAR '12 29 2002 STATE 27. TYPE OF CEREMONY o IIr'RELlGIOUS 10 CIVIL 2B. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNTYDl.(-f",htS's }:']o i( q 29 OFFICIANT C,. lJo I " .L () ().. ' NAME (PRINT) p. ,'- th,P"T' f,J. f(.;:I'I!l')~I.Vl1 SIGNATURE ~ A1 ~ rB. rfi )01'~ MAILING ADDRE,S!" \.. --rF j/ C f. .,tl1Vl S+,'ut WM.o ,'.1Cl e?Y'; kt Ill, STREET CITYn'oWN I 30. WITNESS TO CEREMONY NAME (PRINT) 7~f.SD. ~i{-e.. SIGNATURE~ ,-,Ur'QA.r~,~j::]..( ?" DOH.9B (11/9B) 02 9 0 OTHER. SPECIFY TITLE DATE L~+I.oJ,'" p{,'e~f III CJ /02 , , C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF 0 TOWN OF ~ILLAGE OF SPECIFY Wo.fP,'II'US H: (/~ NtTATE 12'5Qo ZIP 31. WITNESS TO CERE NAME (PRiNT) SIGNATURE ~