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STATE OF NEW YUHK. (THIS SPACEFOR STATE USE ONLY)
DEPARTMENT OF HEALTH ·
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE L 0 SUPPLEMENTAL FILE
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1ST
2ND
D 3RD
D D 4TH
ledge and belief that the information I provided is
A FUll NAME
FROM THE GROOM
Tommv M stevenson
MIDDrE CURRENT SURNAME
FIRST
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
IOPTlONAl ~ SEE REVERSE)
o SOCIAL SECURITY NUMBER 578-74-795?
RESIDENCE A. N Y B. IJLJtchess
(STATE) ICOUNTY1
C CHECK ONE D CITY ~ TOWN [J VILLAGE
AND W .
SPECIFY applnger
o STREET ADDRESS 2 Diddell Road
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VillAGE?
ZIP 12590
D YES ~ NO
3 A AGE 46
3B DATE OF BIRTH
MO
4 EMPLOYMENT
A USUAL OCCUPATION Wt=lrehoLJse Mt=lnt=lger
B TYPE OF INDUSTRY OR BUSINESS Juris Publishing, lnc
5 PLACE OF BIRTH Manhattan" New York
(CITY. STATE'COUN I RY IF NOT USA)
6 FATHER
A NAME Cleve\;:mrl ~evenson
B. COUNTRY OF BIRTH l J S A
7 MOTHER
A MAIDEN NAME Amelia Bryant
B COUNTRY OF BIRTH II ~ A
NUMBER OF THIS MARRIAGE 3
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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B HOW DID lAST MARRIAGE END? (3( ~ DIVORCE 13( D ANNULMENT
C DATE lAST MARRIAGE ENDED? 1? / 1 R /
MONTH DAY
o ARE ANY FORMER SPOUSE(SI ALIVE? ~ES [J NO
(2) D DEATH
?OOO
YEAR
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
1ST 0~~O~~1qR~ AI::lmerl::l Cn , C::llifnrni::l .01. D
2ND 12[1BOOOO WestchF!Ster Co, New YorkD at
~
11. A FUll NAME
FROM THE BRIDE
l alita M Todd
MIDDLE CURRENT SURNAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE ~evenson
(OPTIONAL ~ SEE REVERSE)
o SOCIAL SECURITY NUMBER 1 ?? -nO-n 150
12 RESIDENCE A. N Y B. IJutchess
(STATE) (COUNTY)
C CHECK ONE D CITY cY'TOWN D VILLAGE
AND W '
SPECIFY applnger
D STREET ADDRESS 2 Diddell Road
13 A AGE 24
138. DATE OF BIRTH
ZIP 12590
DYES rt! NO
/1977
YEAR
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE?
09 /11
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATiON Cook
B TYPE OF INDUSTRY OR BUSINESS Westledge Nursing Home
15 PLACE OF BIRTH Peekskill, New York
(CITY, STATE. COuNTRY IF NOT USAi
16 FATHER
A. NAME niveller Torld
B COUNTRY OF BIRTH USA
17 MOTHER
A. MAIDEN NAME Cynthie Travis
B. COUNTRY OF BIRTH l J ~ A
1B NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) ,- DEAT"
B HOW DID lAST MARRIAGE END' (3; D DIVORCE (3( [] ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH OA Y
D ARE ANY FORMER SPOUSE(S) ALIVE? [J YES == 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
YEAR
[J
[J
3RD
4TH
I. being duly sworn, depose and say, that to the best of my k
as to my right to enter into the mar iage state.
21 SIGNATURE OF GROOM ~
23 SUBSCRIBED AND SWORN TO BEFORE M
SIGNA TURE OF TOWN OR CITY CLERK
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
C~ 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
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DATE
01/09/2002
by New Yo~ Dome~c
TIME
MONTH
YEAR
MONTH
YEAR
09:43AM
PM
10 2002
01
10
200
03
28 PLACE WHERE MAP,RIAGE OCCURRED
A STATE NEW YORK B. COUNTy-,,'nu*h~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
== CITY OF ~OWN OF :::: VILLAGE OF
SPECIFy()J Ct- P jJ j rt j c: ,-
31
SIGNATURE ~