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couNnOutchess
CITYITOWNWappinaer
~~~~~CR-' 368
~G~lgJ~rg6
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Philip B. Irvin
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
(J-ifJ(
1/3//C~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Yvette U. Young
MIDDLE CURRENT SURNAME
~
1. A FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I rvin
(OPTIONAL. SEE REVERSE,\, 16-70-9368
D. SOCIAL SECURITY NUMBER I
12. RESIDENCE New York sDutchess
c. CHECK ONE (STA~) CITY "6 TOWN 0 VILLAGE (COUNTY)
~~~cIFWappinqer
D. STREET ADORES? Tor Road
ZI~ 2590
o YEs"'b NO
-ml~
YEAR
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERS,," 0"72 5732
D SOCIAL SECURITY NUMBER I ~ -
2. RESIDENCE ANew York B Dutchess
(STATE) J. (COUNTY)
C CHECK ONE 0 crrY""O TOWN 0 VILLAGE
~~~CIFY Wappinaer
o STREET ADDRESJ Tor Road ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE~O NO
AlQ AQ1~
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGJi;J~ 13.8. DATE OF BIRTH OQ )(1
MONTH DAY
3 A. AGfJ.1
01
MONTH
38. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
8. TYPE OF INDUSTRY OR BUSINEsDutchess County Boces
15. PLACE OF BIRTtBinnhamton1 Np.w York
(C~, STATE/COUN1RY IF NOT USA)
16. FATHER
A. NAMRonnie Young
B. COUNTRY OF BIRM S A
17. MOTHER
A. MAIDEN NAMEAcquanetta Brown
8. COUNTRY OF BIR-ruJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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4. EMPLOYMENT
A. USUAL OCCUPATlo~rchitect
B. TYPE OF INDUSTRY OR BUSINEs~lark Patterson Associates
5. PLACE OF BIRTP~C~~~~/~~~j~,l:~~~A)YOrk
6. FATHER
A. NAMEAndrew Irvin
B COUNTRY OF BIRnU S A
7. MOTHER
A. MAIDEN NAME Ethel OOffley
B COUNTRY OF SIRTHU S A
8. NUMBER OF THIS MARRIAGE1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
(2) 0 DEATH
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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
o 0
o 0
o 0
o 0
legal impediment exists
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1 ST 0 0 1 ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I. being duly sworn. depose and say. that to the best of my knowledge and belief that the information I provided i
as to my right tD enter into the marria S e.
21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e of the
Relations Law 911 to perform marriage ceremonies withi ew 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
{ } NAME (PRINT)GI .
TIME MONTH YEAR
SEAL SIGNATURE
MAILING ADDR SS AM
'-y-I 20 Middlebush Rd 2..58 PM 7
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.
9
06 2002
York Domestic
MONTH
YEAR
09
2002
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY G ~OI'M E-
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~Y OF 0 TOWN OF 0 VILLAGE OF
SPECIFY I?/,...; j /... AM.. -&0..0
NAME (PRINT)
SIGNATURE ~