181
Q.
..... N B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D (OPTIONAL - SEE REVERSE) 119 - 58 -8 21 0
SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE I (COUNTY)
C CHECK ONE ~ CITY 0 TOWN VILLAGE
AND Poughkeepsie
SPECIFY
D. STREET ADDRESS 45 Buckingham Ave Apt.z~ 12601
E. IS RESIDENCE WITHiN UMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 27 3B. DATE OF BIRTH July /20 /1973
MONTH DAY YEAR
4. EMPLOYMENT
w Direct Care
.....~ A. USUAL OCCUPATION
0:;; Anderson School
'" B. TYPE OF INDUSTRY OR BUSINESS
N pouihkeepsie. New York
..... 5. PLACE OF BIRTH
(CfTY, STA COUNTRY IF NOT USA)
6. FATHER
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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Glenn T.
FIRST MIDDLE
I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONL Y)
yJ;D/tJ-!CV
Lo SUPPLEMENTAL FILE --.J
COUNTY lIlutchess
~OWN Wappinger
~ff~k~ 13 68
~5~I~J~R 181
FROM THE BRIDE
Felita D.
FIRST MIDDLE
Simpson
CURRENT SURNAME
Snell
Jr.
11. A. FUU NAME
CURRENT SURNAME
B. BIRTH NAME ;MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE S. Snell
,OPTlONAL . SEE REVERSE)
D SOCIAL SECURITY NUMBER 238 - 2 9 - 2 6 73
12. RESiDENCEA. New York B. Dutchess
,ST4,TE) (COUNTY)
C. CHECK ONE "Ll CITY 0 TOWN 0 VILLAGE
~~:FY Poughkeepsie
D -STREETAOORESS45 Buckingham Ave. AptlzlP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 2tJ YES C NC
13. A. AGE 11 13.B. DATE OF BIRTH Ju 1 v /20 /1969
MONffi DAY YEAR
14. EMPLOYMENT
t-
s:
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c
A. NAME Glenn Snell Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. USUAL OCCUPATION Claims Specialist
B. TYPE OF INDUSTRY OR BUSINESS NY Medical Imaging
15. PLACE OF BIRTH r,reem~Roro. North Carolina
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
Raymond Jerry Simpson
USA
B. COUNTRY OF BIRTH
17. MOTHER
A. MIAIDEN NAME
Florence Cardwell
A. MAIDEN NAME
Goode
Roxanne
USA
8. NUMBER OF THIS M1ARRIAGE Fir s t
B. COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
nSA
First
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS M1ARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? (3) Q DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. ',.I(;W DID LAS-;- MARRIAGE END? (3) 0 DIVORCE
31 0 ANNULMENT
/ /
2! = DEATH
C. DATE LAST \lARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? = 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
MONTH DAY YEAR
D. ~RE ANY FORMER SPOUSE(S) ALIVE? 0 YES ::J NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMlATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
,!AQNTH. DAY. YEAR) (CITY. STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa~
as to my right to enter into the ma .
o
o
o
o
o
o
23. SUBSCRIBED AND S
SIGNATURE OF TO
25,2000
by New York Domestic
w
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This license authorizes the marriage in Ne ork State 01 the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o II checked, this license is to be used only lor the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRIN~ine H. Snowden, Town Clerk
{SEAL SIGNATURE ~~a...U.H ~ ~ "'-11'\< ..lJ ~. DATE 9/25/00 TIME MONTH DAY YEAR
MAILING ADDRESS AM
~ P.O. Box 324 Wappingers Falls, NY 12590 1..00 PM 09
STREET CITYIT WN STATE Z:P
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- ","'-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ELlGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICAT ~ ~ PM 9 0 OTHER, SPECIFY
G
11
24
00
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
26
00
, = CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ ~~.;:~~)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
'i CITY ~ 0 TOWN OF 0 VILLAGE OF
SPECIFY ~ ('I ,:..1 \,,\ \J _. .~;-<i,
It....~
~~
-~
~~ ~;~~\5
CITYITOWNV ".-
SIGNATURE
MAILING ADDRESS
b'\'1 l"<"'n",:, i
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) \)N0.""~ ~'i.. \-\-00
SIGNATURE~~('t \.,..( ~ i\ru.Lt:7i-L
DOH-98 (1198)
SIGNATURE ~