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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Matthew Soame Christianson
MIDDLE CURRENT SURNAME
COUNT"Qutchess
clTYrrowJrlappinger
~J~~~~-' 368
~5~'~J~'82
1 A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSi114-11-4592
D SDCIAL SECURITY NUMBER IE.
2. RESIDENCE AD C B.
(5Ji:TE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY WashinQton
D. STREET ADDREss1255 Ne.'!.t:f!Jmpshire zIP20036
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? "D. YES 0 NO
/24 /1977
DAY YEAR
3 A. AG24
3B. DATE OF BIRTH
10
MONTH
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4. EMPLOYMENT
A. USUAL OCCUPATIONStudent
B TYPE OF INDUSTRY OR BUSINES&Georgetown University
5. PLACE OF BIRTJ"akoma Park: MtiMsnd 0 0
(CITY, STATElCOUNTRY IF NOT"i'ttA)
6 FATHER
A. NAMEChartes Christianson
B. COUNTRY OF BIRnU S A
7. MOTHER
A. MAIDEN NAME Mary numin
B. COUNTRY OF BIRTHU S A
8 NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
(THIS SPACE FOR STA TE USE ONL Y)
M1lt
4' /1
it. ;{'r' t1 ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sarah J . Toll
MIDDLE
-1
11 A. FULL NAME
FIRST
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Christianson
(OPTIONAL. SEE REVERSEJo 13-68-8030
D. SOCIAL SECURITY NUMBER I
12. RESIDENCE D C B.
(S!~TE) (COUNTY)
C. CHECK ONE --0 CITY 0 TOWN 0 VILLAGE
AND lAt hO Qt
SPECIF'/nas In on
D. STREET ADDRES~255 Ne~!:'!Jmpsh;re
ZII20036
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "0
33
DAY
13. A, AG"4
YES 0 NO
1'-477
YEAR
13.B. DATE OF BIRTH
n8
MONTH
14, EMPLOYMENT
A. USUAL OCCUPATIO$tudent
B. TYPE OF INDUSTRY OR BUSINEsJ.lniversity Of Maryfand
15. PLACE OF BIRT~~~l!tT~~j~~Y'?F~OT USA)
16. FATHER
A. NAMDavid Toll
B. COUNTRY OF BIRrEngland
17. MOTHER
A. MAIDEN NAME<lanp. ~nlr1~mith
B COUNTRY OF BIRrfEngland
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
1 ST 0 0 1 ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true a
as to my right to enter into the mar iage state,
TITLE Ep IS (0 /JC{ I (Jrte~1
DATE TIA.Y1e'21 2..(X':)'-
)
mD 207LfD
STATE
21. SIGNATURE OF GROOM ~
23.
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STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED 0 b l.J;o
~~~~n~~I~~T l\ 0. (" \ C\. Lv 0 C\j n Y\
SIGNATURE ~ t CMf.Z~t /J1 - W ~
Mf~L1NG ADDRESS ~ L.-
'15"Il. (nl\~4e live. Col\fbt' Tc..(J..-
STREET ~ CITYiTOWN
30. WITNESS TO C~MO~Y
NAME (PRINT) t5 2tA 4
SIGNATURE ~
DOH.98 (11/98)
o
o
o
2. SIGNATURE OF BRIDE ~
by New York Domestic
TIME
YEAR
ZIP
1 :28 AM
PM
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED _ I
WQ>TC hey
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY J(~erj 0 () Vet lie (
New ~O{t:
NAME (PRINT)
SIGNATURE ~