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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I nrenzo Shawn Childress
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME, IF DIFFERE~ oren'7~ ~h~wn Childress
19. ~~~~~~~RMo'f~1f'~8us MARRIAGES WHICH ENDED BY
~IVORCE CIVIL ~NULMENT
.,
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVO{tj (3) ~~NNULME~oCflfJ DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR M~ DAY' . - 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 ANNULLED. PROVIDE THE FOLLOWING INFORMATION 20, IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUNTY. STATElCOUNTRY.IF NOT USA) SELF SPOUSE (MONTH. DA~X.EARb ICIl;YICOUNTY~TATElCqUNTI\Y.IF NOT USA) SELF SP~SE
1ST 0 0 1ST 10/22/2uu1 Ulcness L,oumy, I''1Y 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm. aep'ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal i ediment exists
as to my righlto enter Into the marnage state, -
21. SIGNATURE OF GROOM. A r , --(J--...- 22, SI ATURE OF BRIDE.
USE CURRENT N
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE 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 ~11to perform marriage ceremonies within New 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) C. Masterson
couN10.L1tchess
CITYlTowWappinger
~~J:~1f 368
REGIST~ 6
NUMBER
1 , A. FULL NAME
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERS~)
D. SOCIAL SECURITY NUMBER 1 09-54-3994
2, RESIDENCE 4\jV IlDutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CI1~ 0 TOWN 0 VILLAGE
AND hk .
SPECIFYPnt Ig eepsle
D. STREET ADDREs93 Aida Dr ZIp12603
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 y~ 0 NO
/15 ,,1959
DAY YEAR
3, A, AG60
3B. DATE OF BiRTH
11
MONTH
4. EMPLOYMENT
A, USUAL OCCUPATION-~nftw~re Engineer
B, TYPE OF INDUSTRY OR BUSINEsElectrical Utilitv
5, PLACEOFBIRT~nunt Hollv, Ni
(CITY. STATE / COUNTRY rF NOT USA)
6. FATHER
A. NAMELor~m7::l ~tew~rt Childress
B, COUNTRY OF BIRTHlJ S A
7, MOTHER
A. MAIDEN NAME Grace Evelyn Swan
B, COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
Lo
~
SUPPLEMENTAL FILE
FROM THE BRIDE
Elizabeth Ann Leenig
11. A. FULL NAME
FIRST MIDDLE
Macken
B. BIRTH NAME (MAIDEN NAM?l: IF ft;EREW'r'
c. SURNAMEAFTERMARRIAGyhl ress
(OPTIONAL. SEE REVERlf~ 2-44-ti4~4
D. SOCIALnCURITY NUMBER h
Y UUIC ess
12. RESIDENC . B,
(STATE) " (COUNTY)
C. CHEC~E hkO crr\'. 0 TOWN 0 VILLAGE
~~~cl~~ug eepsle . \ 9 12G90
D. STREET ADDR""l:S33 Route gO Urul ZIP
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPO'1JD VILLAG~ Ii 0 111ll~ NO
13. A. A~6 3B. DATE OF BIRTH z: 'j'v";
MONTH DAY
CURRENT SURNAME
YEAR
14, EMPLOYMENT d
A. USUAL OCCUPATIO',}nemploye
B, TYPE OF IN~'aSTR:h~~f~~NESS
15. PLACE OF BIR~~an
(CITY. STATE / COUNTRY IF NOT USA)
16, FATHER
A. NAtdohn Edward Macken
'B. COUNTRY OF BIRid ~ A
17. MOTHER G G' . t
Annette . lample ro
A, MAIDEN NAM~ ~
B. COUNTRY OF BIRT~ ~ ~
18, NUMBER OF THIS MARRIAGE
~ATH
DATE 03/15/2010
in ers Falls, NY 12590
CITYITOWN STATE ZIP
26, SOLEMNIZATION OCCURRED 27, TYPE OF CEREMONY
TIM AY YEAR 0 0 RELIGIOUS l~L
I (P / () 9 0 OTHER. SPECIFY
~
{ SEAL }
'-v-I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STREET CITYITOWN
~-~~~+. V\A~
NAME (PRIN r ~I y Id.J
SIGNATURE (Y ) .
o
York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
12:20:~ 03
16
2010
05
14 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN'Pi1u~Lt;(
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFYJ<.,)/l!fH ~
ZIP
". wm..'" m c,~
NAME (PRINT) ~
SIGNATURE~
J~i/~/,Pl