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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
o SOCIAL SECURITY NUMBER
12. RESIDENCEA. Colorado
(STAJ'Fl
C. CHECK ONE I1lI CITY 0 TOWN :J VILLAGE
~~~CIFY Colorado Springs
o. STREET ADDRESS 734 East Bolder StreetzlP 80903
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? XJ YES = NO
13. A. AGE 26 13.B. DATE OF BIRTH Dec. / 11 / 1973
MONTH DAY YEAR
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Eric Richard
tCOUNTY . Dutchess
~~OWN Wappinger
~:r~~~~T 1368
~5~~J~R 94
Miller
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
a.
N
B BIRTH NAME. IF DIFFE.'1ENT
C. SURNAME AFTER MAFRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NU'JBER
2. RESIDENCE A Colorado B. EI Paso
ISTA~ (COUNTY)
C. CHECK ONE 2\. CITY 0 TOWN 0 VILLAGE
~~~CIFY Colorado Springs
o STREET ADDRESS 219 East Dale St. 113 ZIP 80903
469-08-7454
E IS RESIOENCE WITHiN _.MITS OF CITY OR INCORPORATED VILLAGE? :X YES c::: NO
/14 /1973
DAY YEAR
3. A. AGE
26
3B. DATE OF BIRTH
Dec.
MONTH
4. EMPLOYMENT
14. EMPLOYMENT
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
/iJ \1tO\OU
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christine Anne
~
Kelly
CURRENT SURNAME
FIRST
MIDDLE
Miller
064-60-7977
B EI Paso
(COUNTY)
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS A tme 1
5. PLACE OF BIRTH Bloomington. Minnesota
ICITY. STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS D i s t r i c t 1 ~ Colorado Sprine
15. PLACE OF BIRTH Poughkeepsie, 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
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Steven G. Miller
USA
Jean Koller
USA
First
Charles Kelly
USA
Judith Vogt
USA
First
B. NUMBER OF THIS MARRIAGE
lB. NUMBER OF THIS MARRIAGE
DEATH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. HOW DID LAST MARRIAGE END? (3) C DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
,21 = DEATH
B. HOW DID LAST MARRIAGE END? (3) = DIVORCE
C DATE LAST MARRIAGE ENDED?
31 = ANNULMENT
/ /
121 = JEAT~
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? :::J YES 0 NO
, O. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) CITY, STATEcCOUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? == YES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE CF DECREE PLACE :SSUED AGAINST WHOM
IMONTH. DAY. YEAR) (CITY, STATE COUNTRY. IF NOT USA) SELF SPOUSE
1ST 1ST
2ND 2ND
3RD 3RD
4TH 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment eXists
as to my right to enter into the marria state.
21 SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
23. ~~~f:J~~DO~N,.oO~OCRq"~~Bg~~~ ME De ut Town Clerk DATE June.
This license authorizes the marriage in New York ate of the bride and groom named above by any person authorized by New York
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
:J If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
laine Town Clerk
DATE 6/16/00
NY 12590
A
27. TYPE OF CEREMONY
o ~L1GIOUS
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Z
W
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{ } NAME ,PRIN
SEAL SIGNATURE
'-.t-I Mf~IN~~D~R:r~4,
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
9 C OTHER, SPECIFY
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, 2000
Domestic
TIME
MONTH
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
MONTH
DAY
YEAR
YEAR
9:00 AM
PM
8
15
00
17
00
6
1 = CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNT;L71.l'Uft;SS'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
:= CITY OF = TOWN OF ~LLAGE OF
SPECIFY WAfPt~{;€.eS ~