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1368
132
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.T.
MIDDLE
Coffman
CURRENT SURNAME
(THIS SPACE FOR STATE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kelly J.
FIRST MIDDLE
1. A. FULL NAME
Steven
FIRST
Yaw
CURRENT SURNAME
11. A. FUll NAME
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Yaw
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 129-68-3826
12. RESIDENCE A. N\~~TE( 0 r k B J?,MSNfrr e ~ ~
C. CHECK ONE 0 CITY2tJ TOWN [] VILLAGE
~~~CIFY Fishkill
o STREET ADDRESS 257 Town View Dr.
WapP1ngerS taLLs NY
E. IS RESIDENCE WITHIN uMtTS OF CI'M' OR INCORPORATED VILLAGE? 0
13. A. AGE 32 13.B. DATE OF BIRTH May /15
MONTH DAY
YES XI NO
A968
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutehe~~
{STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
o STREET ADDRESS 257 Town View Dr. ZIP 12590
E IS RESIDENCE WITHiN ~iFJ?J ~~I~~RJR~LA~Y
3 A. AGE 26 3B. DATE OF BIRTH Sept. /
MONTH
114-56-1169
ZIP 12590
:J YES IX NO
06 /1973
DAY YEAR
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Retai 1 M2.nag~!'
B. TYPE OF INDUSTRY OR BUSINESS Designs. Ine.
15. PLACE OF BIRTH Erie. Pennsylvania
(CITY, STATElCOUNTRY IF NOTUSA)
16. FATHER
A. NAME Perry J. Coffman
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Dixie J. Phillips
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE Firs t
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. USUAL OCCUPATION Bartender
B. TYPE OF INDUSTRY OR BUSINESS Bugaboo Creek
5. PLACEOFBIRTH Roche~tp..r.New York
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME
Robert G. Yaw
USA
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Linda J. O'Brien
USA
First
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) [J DIVORCE
C. DATE LAST MARRIAGE ENDED?
13\ 0 ANNULMENT
/ /
(2\ :::: DEATH
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? eYES :::: 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
MONTH DAY YEAR
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
0 0
" LJ
'-'
0 :::J
1ST
2ND
3RD
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
Clerk
DAT~Ug .
by New York Domestic
w
U)
Z
W
(.)
::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of 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 If checked, this license is to be used only for the purpose of a second or subsequent ceremony,
~ 24. TOWN OR C~I LERK. 25. A, SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) ~ !-ne H. ~wden
{SEAL SIGNATURE" I'lIIlQ ~~ q~~~l^ TIME MONTH DAY YEAR
MAILING ADDRESS 1 : 45 AM 08 11 00
~ STREET . TAT ZIP PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
~~~SM~~~~~~B~vJH~N Pi~E 0 ~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED 5130 M C> () 9 0 OTHER, SPECIFY
29. OFFICIANT n . , A~' :I~\\ "7") (-"-
NAME (PRINT) ,<;,t"'II. No..f\e>t Hr\:~ ,\ e"~ Ie... TITLE \"'o..5>\V'f
SIGNATURE ~~. fllVnPr ~~-~_ DATE IO/CD fDfl
MAILING ADDRESS e---- ,{ I
4{;40 Mn.1,(\ CJ:-. Arn\-1er-:;A- l\J.,
STREET I CITYfTOWN' STATE
30. WITNESS TO
10
09
00
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Eri ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF B" TOWN OF 0 VILLAGE OF
SPECIFY
A,,U'C'('0-
NAME (PRINT)
SIGNATURE ~
DOH.9B (1/98)
NAME (PRINT)
SIGNATURE ~