163
N
o
Lf'l
C"1
NO.
.... ;;;
t1l
..-I
~
..-I
~~
u: ~
~'r-I
W
(,) I-<
~..-I
w>a:
J: w
~oIoJ~
~ Ul ::>
~ t1l ~
g~~
<( ....
>Oftl
!:!::........a:
~Lnt;
3;Lf'l
~~5 w
~~.... ...
~~gJ .."
.....wz ~
Uld2 CJ
i~g LL:
!~ ~
,; Icn W
~>
IIIUli!i CJ
"'15..
i33;
COUNTY
CITYITOWN
l ~:J~~C:.
REGISTER
NUMBER
STATE OF~!NEW.<YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Joshua Dustin
FIRST MIDDLE
Payne
CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
Dutchess
Wappinger
1368
163
?~\\~\OO CV;71
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULlNAME Melissa Ellen
FIRST MIDDLE
~
1. A. FULL NAME
O'Neil
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 175-60-0533
D. SOCIAL SECURITY NUMBER
2 RESIDENCEA. Virginia B. (None)
(STA~ (COUNTY)
C. CHECK ONE @o. CITY 0 TOWN 0 VILLAGE
~~gcIFY Norfolk
D. STREET ADDRESS 5570 East Virginia ~ 23502
.lHVd.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? IX YES 0 NO
3. A. AGE 20 3B. DATE OF BIRTH Sept. /16 /1979
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. Virginia
(ST~~)
c. CHECK ONE ./l;] CITY 0 TOWN
;gclFY Norfolk
o STREET ADDRESS 5570 ~t Virginia Beach B~ld. 23502
E. IS RESIDENCE WITHIN LIMITS OF CITY"OR INcOHt'URATEO- VILLAGE? Xi YES 0 NO
/31 /1978
DAY YEAR
O'Neil
052-74-8704
B. (None)
(COUNTY)
o VILLAGE
21
13.B. DATE OF BIRTH OC t .
MONTH
13. A. AGE
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Military
B. TYPE OF INDUSTRY OR BUSINESS U. S. Navy
5. PLACEOFBIRTH Oil City, Pennsylvania
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Mili tary
B. TYPE OF INDUSTRY OR BUSINESS U. S. Navy
15. PLACE OF BIRTH PortSmouth',. Virginia
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME Earl Peter O'Neil
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Lisa Marie Dillinger
B. COUNTRY OF BIRTH USA
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
Kenneth W. Payne, Jr.
USA
8. NUMBER OF THIS MARRIAGE
First
D~.bl'H';a Lee Dagenkolb
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE Firs t
A. MAIDEN NAME
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(210 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
,210 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? iJ YES 0 NO
1 D. 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. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES C 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 USAI SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the marri
w
en
z
w
CJ
::;
o 0 1ST
o ,..., 2ND
o :J 3RD
o '1 4TH
ledge and belief that t e InfDnnal10n I prOVided IS true and that I declare that no legal Impediment eXists
22.SIG~ATUREOFBRIDE~~~ _~
De ut Town ~ePt. 11. 200e
This license authorizes the marriage in New York Stat 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.
o If checked. this license is to be used onl for the urpose of a second or subsequent ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Elaine Town Clerk
DATE 9/11/00
10 :OOAM
NY 12590 PM 9
ZI
,...,
c
:--
21. SIGNATURE OF GROOM.
~
{ SEAL }
'-v-I
NAME (PRI
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
12
00
11
10
00
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PlACE INDICATED.
27. TYPE OF CEREMONY
DR RELIGIOUS 1 c: CIVIL
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY :0.:.' h/c?.;~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .l!lI' TOWN OF 0 VILLAGE OF
SPECIFY ~/1er
TITLE
f e,,'~ :-~,1()
o
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE.
DClH-8ll (1JlI8)