149
COUNTY Dutchess
CllY/TOWN Wappinqer
~~~~~c~ 1368
~~~'~l~R 149
:1
0-
N
o
Z:i:z
~t:Q
I-~I-
W <i
a:>ON
a:-
I- W Z
Vl--,::;
::lOW
~t90
I-ZVl
z-
~~LL
OVlO
tEoU)
01->-
w~c3
b~~
Z::i~
A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jr. Ronald Ireland
MIDDLE CURRENT SURNAME
FIRST
,.-
I
(THIS SPACE FOR STATE USE ONL Yi
Ntf astv
tJaf. ~, tt'o J
v?1Cj~q8"j3
L [l SUPPLEMENTAL FILE
FROM THE BRIDE
Tammy J. Tompkins
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Ireland
(OPTIONAL SEE REVERSE) 053-60-8539
D SOCIAL SECURITY NUMBER
12 RESIDENCE A New York B. Outcl1~ss
(STATE) (COUNTY)
C CHECK ONE D CITY D ,",OWN D VILLAGE
~~~CIFY Wappinaer
D STREET ADDRESS 324 \\'1vers Comers Road ZIP
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
13 A AGE :lQ 13.B. DATE OF BIRTH '11 / 1:l
MONTH DAY
'12590
YES D""f.lo
/1Q71
YEAR
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE) '126-52-6998
o SOCIAL SECURITY NUMBER
2. RESIDENCE A New York B Dutchess
(STATE).4 (COUNTY)
C CHECK ONE D CITY D-rOWN D VILLAGE
~~~CIFY Wappinqer
D STREET ADDRESS 324 M'iers Comers Road
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A AGE 41 3B DATE OF BIRTH 06 /
MONTH
ZIP 12590
DYES D'" NO
27 / 196
DAY YEAR
14. EMPLOYMENT
4. EMPLOYMENT
A USUAL OCCUPATION
A USUAL OCCUPATION Oomestic Engineer
B. TYPE OF INDUSTRY OR BUSINESS Homemaker
15. PLACE OF BIRTH Peekslcill, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAME Eugene Tompkins
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME T er~~a Bllf-Je
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
n
(2) [] DEATH
Painter
B TYPE OF INDUSTRY OR BUSINESS Self Employed
5. PLACE OF BIRTH Peekskilt. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A NAME Ronald Ireland
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME G.p.rRlriinp. Wintp.r~
B. COUNTRY OF BIRTH l J S A.
B NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
B HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
C DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
ffi
<Xl
:;;
OJ
Z
C>
Z
<<
I-
W
W
g:
<J)
15T D D 15T D D
2ND D D 2ND D II
3RD D D 3RD D D
4TH D D 4TH D D
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that 1 declare that no legal impediment exists
as to my right to enter into the marriage state.
;;2:>
22. SIGNATURE OF BRIDE ~
21. SIGNATURE OF GROOM
'11/0112001
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
{ SE. A},};~JA7i~:~~, 10' ': "-... .~L 111011200' ""' MO"," "" """'"
, . MAILING ADDA ' . AM
~ 20 Mi alebush F ~ "11 08 20 1 01
.., STREET
I C-fi;RTIFY TfJAT I SOLEMNIZED 26. SOLEMNIZA '} 28. PLACE WHERE MARRIAGE OCCURRED
nlE'MARRlAGE OF THE PER, ,'<
~NS.NAMtD '!\SOVE ON THE TIME ' NEW YORK
DATE AND 'oAf T.HE liME ,AND, AM ~ A. STATE B COUNTY
PLACE INtllCA=,'" ~'-' PM \l"
~ ;~DF;:;r~~;t::;.,<~ . ~V ~ \,~.~ C ~~~:~~O~N~FA:R:~~~;y)
<( NAME (p~lNtf, ' ';_ '- .',;' ~ 11
~ SIG~~fu~~ ~ .,' : }t;:' . ' /,,' ~.f ~ ji ~ 1./1' r-- U c,~ 0' n >OWM 0' n "CC"O' 0'
i= MAILING ~DCRC'S:-{ . " $1 ~ ~ ~ ~ SPECIFY
ffi STREET CITY/T ~ '\. 'I.. ~\':""J ,p
U 30. WITNESS TO CEREMONY .~ '" " AONY
w
CJ)
Z
W
U
:J
YEAR
06 200,1
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
SIGNATURE ,.