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COUNTY
~r.;OWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Darrin F.
FIRST MIDDLE
I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONL Y)
'/9/~~1p()
L [J SUPPLEMENTAL FILE -1
FROM THE BRIDE
Jessica A.
FIRST MIDDLE
Ford
CURRENT SURNAME
Dutchess
Wappinger
1368
175
I~
N
Bonner
1. A. FULL NAME
11. A. FUll NAME
B. BIRTH NAME ,MAIDEN NAMEI. IF DIFFERENT
Bonner
n/a
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
o CITY :J TOWN ~ VILLAGE
Wappingers Falls
77 Paggi Terrace
CURRENT SURNAME
B BIRTH NAME, IF DIFFERENT
ZIP
12590
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 116-56-2821
o SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE = CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
o STREET ADDRESS 77 Paggi Terrace ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
/18 /1969
DAY YEAR
C. CHECK ONE
AND
SPECIFY
13. A. AGE
D. STREET ADDRESS
27
13.B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
Dec. /13 / 1972
YEAR
3. A. AGE
30
Oct.
MONTH
MONTH
DAY
A. USUAL OCCUPATION Lost Prevention
8. TYPE OF INDUSTRY OR BUSINESS Home Depo t
5, PLACE OF BIRTH Queens County, New
(CITY. STATE/COUNTRY IF NOT USA)
York
A. USUAL OCCUPATION Secre tary
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTH Colon, Panama
(CITY, STATE/COUNTRY IF NOT USA)
1ST 0 0
2ND 0
3RD 0 -
, ,
w
(/)
Z
W
o
::i
24, TOWN 0
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-,-I "~N<jf8~R'j~4,
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA TED.
DATE
NY
9/20/00
12590
38. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. NAME Car los (unknown)
B. COUNTRY OF BIRTH Cuba
7. MOTHER
A. MAIDEN NAME
A, NAME Ricardo Ford
B, COUNTRY OF BIRTH Panama
17. MOTHER
A
27. TYPE OF CEREMONY
o 0 RELIGIOUS
6. FATHER
16, FATHER
B. COUNTRY OF BIRTH
Leoulla Bonner
USA
First
A. MAIDEN NAME Theodosha Frasier
B. COUNTRY OF BIRTH Panama
First
29. OFFICIANT
NAME (PRINT)
18. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
(3) 0 DIVORCE
131 :J ANNULMENT
/ /
21 = DEATH
8. NUMBER OF THIS MARRIAGE
B. HOW DID LAST MARRIAGE END?
(31 C DIVORCE
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
YEAR
C. DATE i.AST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
3) 0 ANNULMENT
/ /
MONTH DAY
D ARE ANY FORMER SPOUSE(S) ALIVE? = YES = NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) ICITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
MONTH DAY
D ARE ANY FORMER SPOUSEiS) ALIVE? 0 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
that I d~are that no I~I impedi~nt psts ,
"'r!o./ /C. 17c~
USE CURRENT NAME
23. Deputy To Clerk DATE Sept. 20, 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.
CL~!ne H. Snowden, Town Clerk 25. A. SOLEMNIZATION PERIOD BEGINS
YEAR
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
~IZ
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11 : OOAM
PM
9
00
19
00
21
11
1~.
28 PLACE WHERE MARRIAGE OCCURRE~
A STATE NEW YORK B COUN~*~c::5
C LOCATION OF CEREMONY
(CHECK ONE AND ~IFY)
.0 CITY OF ~W~ OF 0 VILLAGE OF
SPECIFY I {/1/ ",fJ ) 11- ~ f'r.
~ I' /.
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