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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 ~