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23;
,
STATE OF NEW 'YORK-J
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Steven R.
FIRST MIDDLE
STATE FILE NUII8ER
(THIS SPACE FOR STATE USE ONLY)
I
COl.~TY Dutchess
~~WN Wappinger
~~~~<;i 1368
~5~~~R 99
/~Av~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULLNAME Darla L.
~
Hickman
Hickman
CURRENT SURNAME
MIDDLE
FIRST
1. A. FULL NAME
CURRENT SURNAME
Curry
Hickman
090-50-6272
B Dutchess
(COUNTY)
VilLAGE
B BIRTH NAME. IF DIFFERENT
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
New York
(STATE)
C. CHECK ONE 0 CITY Xl TOWN 0
~~CIFY Poughkeepsie
o STREET ADDRESS 621 Sheafe Rd. /139 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Ki NO
13.B.DATEOFBIRTH June /01 /1960
MONTH DAY YEAR
131-48-5766
12. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
3. A. AGE
43
13. A. AGE
40
3B. DATE OF BIRTH
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION
Assemblier
L & E Electronics
New York
4. EMPLOYMENT
A. USUAL OCCUPATION Fac tory Worker
B. TYPE OF INDUSTRY OR BUSINESS L & E Electronics
5. PLACE OF BIRTH Beacon. New York
ICITY. STATE/COUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OB BUSINESS
15. PLACE OF BIRTH pou~hkeepsie.
(CITY. STATElC NTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Audrey Caswell
USA
Second
Raymond Hickman
USA
William B. Curry
USA
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
Ruth
Eganburger
USA
Second
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
One
DEATH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
One
DEATH
B. HOW DID LAST MARRIAGE END? (3) X DIVORCE (3) C ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? N OV . / 22 / 1994
MONT.ti DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? .15l YES C NO
20. IF PREVIOUSLY DIVORCED OR ANNUlED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY. STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
11/22/94 poughkeepsie, NY ~
w
en
z
w
o
:J
YEAR
21
00
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY PUTClI-t9
C.
29. OFFICIANT
NAME (PRINT)
o CITY OF TOWN OF 0 VilLAGE OF
SPECIFY wr r:;r.'f v { u-
NAME (PRlN'fl
SIGNATURE .