107
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I, being duly sworn, dePOs~ay, that to the best of my knowledge and belief that the information I provided is true and that I declare that no leg
as to my right to enter into t riage state,
- .
21. SIGNATURE OF GROOM . 22. SIGNATURE OF BRIDE ~
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STATE OF,NEW.YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Damien Christo~her Powell
FIRST MIDDLE CURRENT SURNAME
COlJ\lTY
. Mi~fTOWN
DISTRICT .
NUMBER
REGISTER
NUMBER
Dutchess
WapDinger
1368
107
1. A. FUll NAME
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE)
C. CHECK ONE [] CITY IX TOWN 0 VilLAGE
AND
SPECIFY Pleasant Valley
D. STREET ADDRESS 13 Spring Creek Drive ZIP 12569
ADt. Iu~
E. is RESiDENCE WITHiN LIMITS Of1'CITY OR INCORPORATED VilLAGE? 0 YES IX NO
3. A. AGE 22 3B. DATE OF BIRTH Feb-. /12 /1978
MONTH DAY YEAR
074-68-3977
B. Dutchess
(COUNTY)
4. EMPLOYMENT
A. USUAL OCCUPATION Manuf ac turing
B. TYPE OF INDUSTRY OR BUSINESS Manpower
5. PLACEOFBIRTH Manhattan, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Herbert Powell
USA
Mary Lee Edwards
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? (31 C DIVORCE ,31 0 ANNULMENT 121 [] DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
u. ARE ANY FORMER SPOUSE(S) ALIVE? [] YES :::J NO
10. IF PREVIOUSLY DIVORCED OR ANNUlED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR I (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
r
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
/11'~OV
L 0 SUPPLEMENTAL FILE
I
-.J
11. A. FULL NAME
FROM THE BRIDE
Lauren Courtney
FIRST MIDDLE
Smith
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
0, SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B Dutchess
(STATE) . (COUNTY)
C. CHECK ONE [] CITY ~ TOWN [] VilLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 5 Merry Hill Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES!i NO
13.B. DATE OF BIRTH July /26 /1982
MONTH DAY YEAR
Powell
051-72-7460
13. A. AGE
17
14. EMPLOYMENT
A. USUAL OCCUPATION S tuden t
B. TYPE OF INDUSTRY OR BUSINESS Dutchess Corom. College
15. PLACE OF BIRTH Tarrytown, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
Robert C. Smith
USA
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME Cynthia S. Owens
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE First
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. HeW DID LAST MARRIAGE END? (3) 0 DIVORCE 13) 0 ANNULMENT 121 C DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH , DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ::J YES' r:::: 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
W
(J)
Z
W
(,)
::::i
~
{ SEAL}
'-v-I
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New. York S ate 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 onl for the purpose of a second Dr subsequent ceremony.
24. TOWN OR C CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
lai e
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA TED.
Town Clerk
DATE Jul y 11. 2000
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
21
3:00
AM
PM
00
7
12
00
9
9
A
27. TYPE OF CEREMONY
o Ii( RELIGIOUS
9 [] OTHER, SPECIFY
1 C CIVil
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY L:?U'';Or~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
LJ CITY OF [] TOWN OF ~ VilLAGE OF
SPECIFY W""'~,v6.-7"HS ,;,~S
~
NEW YORK STATE DEPARTMENT OF HEALTH
BlJreau ot Vital Records
Certificate of
Consent
~f!IBlfil@fi~!!lil!lllil~~III~l~~[~!L~~~~:;:i!i!!~!I~~!111~~~I!I~I!~IIIII!~~lil~l~ii~i!li!i::iii!!~!i
............ .... ............... .......................................................................................................-r..Di~t~i~i.... ............................................................................................
-- ..~.~~~.......................~.~~.?~:~.~.....................................................................!...~.~~.~.~.......................~.~.~.~...............................................................
! Register
...~~~.".................~~~E~.?~.~.................................................................1...~~.~~~..........................~.~!..............................................................
This is to certify
, who have.hereto subscribed
name, do hereby consent that
(I, we)
(name of minor)
who is
and who is under the age of
years, shall be united in
(my or our son or ward)
marriage to
by any minister of the gospel or other person authorized by law to solemnize marriages.
Witness my hand this
day of
19
~............................................_...................................
'-'
~......................-.w..................................................................................................
(Signatures of Parents or Guardians)
~........................................................................................................
(Signature of Issuing Clerk or a Notary Public)
This is to certifyW f> J' , who have hereto subscribed 0 Lt (" name, do hereby consent that
l (I, we) (b L. S (my'rou~)
QU V"'P \1\ l_DLl 'TY\e.~ rY\ \i-\,\
name of minor)
who is 0 U (' r1 a u~ h. te ( and who is under the age of \ g years, shall be united in
(my or our daug r or ward)
marriagolo D (A ill i e., Y\ 0..1 r i s +Dp~ e r ~ weJ 1
by any minister of the gospel or other person authorized by law to solemnize marriages.
Witness my hand this \ ~ day of J LA. \ ~ 11t- 'L DO 0
~_.~_~bt_~iI__
~ ......... ..... -JJhLLVJ~Lm
~~::~L
(Signature of Issu' g Clerk or a Notary Public)
'-'
DOH-2279 (4188) p. 1 of 2
(OVER)