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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Oliver A.
COUNTY Dutchess
~miTov.:..'l Wappinger
~~J~~~r 13 6 8
~G~~J~R 1 95
1. A. FULL NAME
Johnson
CURRENT SURNAME
FIRST
MIDDLE
0-
N
8 BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
(COUNTY)
110-70-5982
B.
(STATEI
Xi CITY C TOWN := VILLAGE
Poughkeepsie
3 Gray Street
ZIP 12603
D. STREET ADDRESS
E. IS RESIDENCE WITHiN LIMITS OF CITY OR iNCORPORATED VILLAGE? X:J YES LJ NO
/23 /1971
YEAR
3. A. AGE
29
3B. DATE OF BIRTH
Aug.
MONTH
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Vendor
B. TYPE OF INDUSTRY OR BUSINESS Mid-Hudson Vending
5. PLACE OF BIRTH Kings ton. Jamaica
(CITY. STATEiCOUNTRY IF NOT USA)
6. FATHER
I- A. NAME Philip Johnson
:> B. COUNTRY OF BIRTH Jamaica
<C
C 7. MOTHER
u::: A. MAIDEN NAME Laurel Peterkin
LL Jamaica
<C B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
8. HOW DID LAST MARRIAGE END? 131 = DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) C DEATH
(31 C ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? = YES C 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
w
en
z
w
o
~
~
{ SEAL }
'-v-'
NAME (PRINT
SIGNATURE
MAILING ADDRE
PO Box
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
o 0 RELIGIOUS
9 0 OTHER. SPECIFY
29. OFFICIANT
NAME (PRINT)
8. BIRTH NAME ',MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A New York
(ST#E)
C. CHECK ONE ~ CITY = TOWN n VILLAGE
~~~C:FY Poughkeepsie
D STREE""ADDRESS 3 Gray Street ZIP 12603
_. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? X= YES C NO
Sept. /30 ~976
MONTH DAY YEAR
11 A. FULL NAME
13. A. AGE
14. EMPLOYMENT
I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE ONL Yi
~lovt/nV
Lo SUPPLEMENTAL FILE ~
FROM THE BRIDE
Wendy Lee
FIRST MIDDLE
Fish
CURRENT SURNAME
Johnson
099-62-8547
B.
Dutchess
,COUNTY)
24
13.8. DATE OF BIRTH
A. USUAL OCCUPATION General Office Work
B TYPE OF INDUSTRY OR BUSINESS Collection Recovery Srvc
15. PLACE OF BIRTH Syracuse, New York
ICITY. STATEiCOUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17 MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
Wayne Gary Fish
USA
Jamie Pelkey
USA
First
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
3. HOW DID LAST MARRIAGE END? (3) CJ DIVORCE
C. DATE cAST MARRIAGE ENDED?
]) = ANNULMENT
/ /
2' = DEATH
MONTH JAY YEAR
J. ARE .ANY FORMER SPOUSE(S) ALIVE? = YES = NO
20. F PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
:MONTH. DAY. YEAR) (CITY, STATE/COUNTRY. IF ,,"OT USA) SELF SPOUSE
31.
NAME (PRINT)
SIGNATURE.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON'
TIME
YEAR
YEAR
1ST 0 1ST
2ND i:J 2ND
3RD 0 3RD
4TH 0 4TH
I, being duly sworn, depose and say. that to the best of my knowledge and belief that the :ntormalion I provided is true and that I declare that no legal Impediment eXists
as to my right to enter into the m~e state. ~
21. SIGNATURE OF GROOM. LJ\il,;~ ( 22 SiGNATURE OF BRIDE. ~J ~~ I i
. ~ C RENT NAME
23. ~~B;A'r~~~DO~NT~~~OtRN ~<fvBg~:~~E De u t Town Clerk DATE Oct. 3, 2000
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
= 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
Elaine Town Clerk
DATE 10/3/00
NY 12590
STATE
27. TYPE OF CEREMONY
MONTH
DAY
MONTH
DAY
AM
ZIP 2: 30 PM
1/clVIL
4
12
2
00
00
10
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
::J CITY OF ::J TOWN OF ~ILLAGE OF
SPECIFY