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STATE OF NEW YORK I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONLY)
COUNTY nUtr.hASS DEPARTMENT OF HEALTH
CITYITOWN WFlppinger
~~~~~c; 1 ~nA . AFFIDAVIT, LICENSE and
~~~I~~~R 11 n CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE .-J
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Dao,bi~ Robert JigijepSURNAME 11. A. FULL NAME Se~nnnn r,::Irv~
FIRST FIRST I OLE C RENT SURNAME
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N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Horton
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 059-74-A579
12 RESIDENCE A. NYsTATE) B. ~~~t~~r!=;S
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY BAFlr.nn
D. STREET ADDRESS 29 N Chestnut St.: Apt 2 ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? I!'f YES 0 NO
13. A. AGE 31 13B.DATE OF BIRTH 1 n /18 /1978
MO~TH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 088-R4-R? 1 Q
2. RESIDENCE A. N;tATE) B. QMt~ess
c, CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Beacon
D. STREET ADDRESS ?Q N ChA!=;tnllt ~t : Apt 2 ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
MO~~ / D~3 / yl~78
3. A. AGE 32
4. EMPLOYMENT
A. USUAL OCCUPATION Technical Writer
B. TYPE OF INDUSTRY OR BUSINESS IT
5. PLACE OF BIRTH (~~?s'?!r~Y~(JN~Y;F NOT USA)
6. FATHER
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION T A::Ir.hAr
B. TYPE OF INDUSTRY OR BUSINESS WCSD
15. PLACE OF BIRTH POlJnhkeeosie, NY
(CITY, SfJ;TE / COUiJi'RY IF NOT USA)
16. FATHER
A. NAME V\Iilli::lm r-.::IrvAY
'B. COUNTRY OF BIRTH Sr.otlFlnd
17. MOTHER
A. MAIDEN NAME DnnnFl Louise Gould
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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A. NAME James Henry Horton
8. COUNTRY OF BIRTH 11!=3 A
7. MOTHER
A. MAIDEN NAME \<~thle~n Tnll!=;~Y
B. COUNTRY OF BIRTH II S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE . CIVIL ANNULMENT
DEATH
n
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
iment exists
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In
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the information I provided is tru a
22. SIGNATURE OF BRIDE~
SEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized
Relations Law ~11 to perlorm 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
n C.
DATE
by New York Domestic
~
{ SEAL }
'-v-'
sterson
MONTH
YEAR
NAME (PRINT)
YEAR
TIME
MONTH
DATE 09/01/201
ush Rd. WaD~in~ers Falls. NY 12590
C TYITO N STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 it RELIGIOUS
I AM
.. '. ~ 0 9 0 OTHER, SPECIFY
SIGNATURE ~
MAILING ADORES
20 Middl
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
08:3()\M
PM
09
02
2010
10
31 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 0'4 P. he s'5
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY F~< ~ 1(; J I
10 CIVIL
TITLE~('
DATE~ 10
{ViiI 11603
STikE ZIP
31. WITNESS TO
30. WITNESS TO
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-9a (09/2009)
SIGNATURE~