148
:1
0-
N
o
m
10
N
~
>=
z
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Eric l. Hickm an
Dutchess
COUNTY
wappinger
CITYfTO~I')..
DISTRICT'} :,6ti
NUMBER
REGISTER 14ti
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE099-72-9853
D. SDCIAL SECURITY NUMBER
2 RESIDENCE A. N Y B. Dutchess
(STATE) vi (COUNTY)
C. CHECK OItEa. 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY wappinger
1668 Rte. 9 Apt. 6 H
D. STREET ADDRESS
-12590
ZIP
.".
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
3 A AGE30 3B. DATE OF BIRTH 11 /23 /1971
MONTH OA Y YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Computer Consultant
B. TYPE OF INDUWRrJR.BUSJNESS Pfullps ~mlcond0c10rs
5. PLACE OF BIRTH (;0 !;Sprang, New YO
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
I- A. NAME Edward Hickman
:> B. COUNTRY OF BIRTH U ~ A
7. MOTHER
A MAIDEN NAME Pauline Washington
B: COUNTRY OF BIRTH U 51 A
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~CE CIVIL A1:iULMENT
D~TH
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
/}1~
\
II~ 7-tJ~
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Linda A. Coffer
11. A. FULL NAME
FIRST MIQl2l.E CURRENT SURNAME
I nompson
B. BIRTH NAME (MAIDEN NAMEI, ~FF'RENT
C. SURNAME AFTER MARRIAGE Ie man
(OPTIONAL - SEE REVERSE) 1 (J 1-56-4(J(J~
D SDCIAL SECURlTY NUMBER
12. RESIDENCE AN Y 8. Dutchess
(STATE) vi' (COUNTY)
C. CHECK O~Ji. D CITY 0 TOWN 0 VILLAGE
AND wappinger
SPECIFY 1668 ~lt::. 9
D. STREET ADDRESS - . -.,
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED '{tLAGE? 0 Yj..97 4'0
13. A. AGE 28 13.B. DATE OF BIRTH 0 ~2 ~
MONTH OA Y YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION C N A Wfi .
"ngale
B. TYPE OF INDu.'iIRY OR. BUSINl"SS ~d I
I'\lngslOn, ...enns.J.van 8
15. PLACE OF BIRTH .
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAME Frank Thompson
B: COUNTRY OF BIRTHU 5 A
17. MOTHER L' d A t'd .
A. MAIDEN NAME In 8 n I orml
B. COUNTRY OF BIRTHU S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI1RCE CIVIL AN~ULMENT
DEbTH
.,.
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (31 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVOm (3) ~NULMENT 2d6~ DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTH OA Y YEAR MONTtV' OA Y YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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 DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (bAQI'JW'%Y9~)D' <CITY, STATE/CA1UNT~,.IF NOT.IJS^1. SELF SPOU9
o 0 1ST lU/U4n ,~~ Ulcness \"'0" New YOJI\ 0 0
o 0 2ND 041i!Z'lUUl Uutcness (';0., New York ci 0
o 0 3RD 0 0
o 0 4TH 0 0
y knowledge and belief that the information I provided is tr - e al impediment exists
II:
w
OJ
::;;
::l
Z
o
z
'"
0-
W
w
II:
0-
W
1ST
2ND
3RD
4TH
I, being duly sworn, depose an ,
as to my right to enter into the marriage st
w
CJ)
Z
W
(J
::i
&fREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
z Z PLACE INDICATED.
II: 0 W
::> ;::
.... I-
w ~ 29. OFFICIANT
II: <(
0- Z NAME (PRINT)
(f) ::;; (J
::> w
::;; -' u::
0
0- (f)
z t=
'" u.
<3 0 a:
u:
u. (f) W
0 >-
<( (J
jj 0
:)
z ~
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY /lvrli</5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY ;;'~j;iI /tIf
NAME (PRINT)
SIGNATURE ~