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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. Rll NAME J enelle Delyse
FIRST M100LE
1. A. FUll NAME
STATE OF,NEW'IYORK,r
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Randolph
FIRST
COUNTY Dutchess
~ITOWN _ Wappinser
~~~~ .. 1368
~5~~~R 144
MIDDLE
Ward
CURRENT SURNAME
...
N
B. BIRTH NAME, IF DIFFERENT
054-64-2693
35
June
13.A. AGE 31
14. EMPLOYMENT
3B. DATE OF BIRTH
3. A. AGE
4. EMPLOYMENT
MONTH
STATE FILE ..-..
(THIS SPACE FOR STAn: USE OM. \?
/ql~,v
I
.J
Redley
CURRENT SURNAME
Blue
Ward
125-66-1623
B. Dutchess
(COUNTY)
o VILLAGE
13.B. DATE OF BIRTH Dec.
MONTH
Butcher
Grand Union
New York
A. USUAL OCCUPATION Cashier
B. TYPE OF INDUSTRY OR BUSINESS Wa lma r t
15. PLACE OF BIRTH Yonkers. New York
(CI1Y. STATEJCOUNTRY IF NOT USA)
A. NAME Bobby Blue
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH (CITY, ~~mJ~~~t~e:? ·
6. FATHER
16. FATHER
A. NAME James Ward
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Fannie Green
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
Sharon Sharrock
USA
Second
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
B. HOW OlD LAST MARRIAGE END? (3) IX DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? Feb. / 22 / 1992
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? Qli YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATlON
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
2/22/92 White Plains, NY Xc c
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York tate of the bride and groom named
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID YORK STATE ONLY.
o If checked. this license is to be used on for the rpose of a second or su uent ceremony.
24. TOWN OR RK 2S. A. SOLEMNIZATION PERIOD BEGINS
Elai e Town Clerk
DATE 8/24/00
NY 12 90
DEATH
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
o
o
o
o
e best of my knowledge and
o 1ST
o 2ND
o 3RD
o 4TH
lief that the Information I provided is
w
en
z
w
CJ
::i
~
{ SEAL }
'-.t-'
1 0 ClV1L
DEATH
25. B. SOI.BoNlATlON PEIlIOIl
ENlSAT_ON:
TIME
MONTH
DAY
YEAR
MONTH DAY YEAR
2:45
AM
PM
8
25
00
10 23 00
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~ ik}-e~
C. LOCATION OF CEREMONY
(CHECK ON~ SPECIFY)
o CITY OF r; ~OWN OF g VILLAGE OF
SPECIFY tJlJ.fJ /'l H G 1f".If?.