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COUNTY Dutchess
CITYITOWN Wappinger
~~~:~c; 1368 .
~5~1:~~R 96
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
GeJ?o~qe Mose KJ~a~T SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L
1 . A. FULL NAME
11. A. FULL NAME
o SUPPLEMENTAL FILE
FROM THE BRIDE
Terry-Ann Tesha-Gay HardinJt
FIRST MIDDLE CURRENT SUR AME
~
FIRST
D..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 111-92-0849
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 3 Pembroke Circle; Apt B ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
3. A. AGE ~? 3B. DATE OF BiRTH 04 / 24 / 1978
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ha rd i ng-Kiag e
(OPTIONAL. SEE REVERSE) 071 72 7939
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r'!1 TOWN 0 VilLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 3 Pembroke Circle; Apt B ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/2.7 /1984
DAY YEAR
13. A. AGE 25
13B.DATE OF BIRTH
11
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Pharmacist
B. TYPE OF INDUSTRY OR BUSINESS Pharmacy
5. PLACE OF BIRTH Kisii. Kenya
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Stephen Kiage Ongara
B. COUNTRY OF BIRTH Kenya
7. MOTHER
A. MAIDEN NAME Betsua Nyarinda Abner
B. COUNTRY OF BIRTH Kenya
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Pharmacist
B. TYPE OF INDUSTRY OR BUSINESS Pharmacy
15. PLACE OF BIRTH Kingston, Jamaica
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Eaton Keith Hardina
'B. COUNTRY OF BIRTH Jamaica
17. MOTHER
A. MAIDEN NAME Orlean Campbell
B. COUNTRY OF BIRTH Jamaica
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
,.
2D. 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
C. DATE LAST MARRIAGE ENDED?
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true rd that
as to my right to enter into the marriage state. /
./ ~ ,/,
21 SIGNATURE OF GROOM ~ !]:' 22 SIGNATURE OF BRIDE ~--. iJ"
USECU I ,
23 SUBSCRIBED AND SWORN TO/AFFIRM BEFORE ME (
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New Y State of the bride and groom named above by any person authorized by New York Domestic
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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masterson
{ SEAL SIGNATURE~ ~C'1~ DATE 07/29/201 TIME MONTH YEAR MONTH
'-v-' MAI'i6 ~aar~ush Rd, Wappingers Falls, NY 12590 07 30 2010 09 27 2010
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27~. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMEO ABOVE ON THE TIME MO. DAY YEAR 0 RELIGIOUS 1 0 CIVIL
~tl6E ~~gIC'j,,~;6'E TIME AND '0 9 0 OTHER, SPECIFY
o
o
o
'9/2010
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 111- 8 ffN.
29. OFFICIANT
NAME (PRINT)
P~rptQ
DATE 7/0 / I "
A/Y !z..?J)r
STATE ZIP
31. WITNESS TO EREMONY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY AI bQt?j
NAME (PRINT)
SIGNATURE~