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CITYfTOWN W~ppingAr
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ti ~glpy Scott ~~~~ SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
K~~Lynn He~S)(ENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~S~~~EJ,.,~~~rt~~C~~sJ3ither
D. SOCIAL SECURITY NUMBER 07Q-7R-QRQR
12. RESIDENCE A. \Iii.
. (STATE)
C. CHECK ONE ~ CITY 0
AND
SPECIFY RO::lnnkA
D. STREET ADDRESS 918 St~ IJ nto n Ave ZIP 24016
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
~~H /1Zv /i~g7
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 137 -82-8569
2. RESIDENCEA. V~ATE) B. ~~oke
c. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Roanoke
D. STREET ADDRESS 91 R ~t~llntnn AVA ZIP ?401 R
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Clt YES 0 NO
MoSil / oRG / v!~81
B. ~9,~ke
TOWN 0 VILLAGE
3. A. AGE 29
4. EMPLOYMENT
13. A. AGE 22
3B. DATE OF BIRTH
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Movie Theatre Personnel
B. TYPE OF INDUSTRY OR BUSINESS SArviC:A Innll5:try
15. PLACE OF BIRTH RhinAhAc:k NAW York
(CITY, STATE I COUNtRV IF NOT USA)
16. FATHER
,A. NAME Ralph Edward Heady
B. COUNTRY OF BIRTH I J ~ A
17. MOTHER
A. MAIDEN NAME ~11!=:::InnA A Now~k
B. COUNTRY OF BIRTH I J S A
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. USUAL OCCUPATION Tech Support
B. TYPE OF INDUSTRY OR BUSINESS Telecomm'lniC:::Ition
5. PLACE OF BIRTH (!;,r),QR~ /~trN9[~gT ~~Ilnty. Mary1e'1d
6. FATHER
A. NAME Harry.4.. Bither
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Lynn Newcomb
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH OA V
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- VEAR
,.
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRV, IF NOT USA) SELF SPOUSE
1ST 0 1ST
a: 2ND 0 2ND
UJ
'" 3RD 0 3RD
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DATE
by New York Domestic
~
{ SEAL}
'-v-I
NAME (PRINT)
TIME
MONTH
YEAR MONTH
YEAR
AM
12:5Q:>M
08 10 2010 10 08 2010
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY:PU, TC. Hi'
c. LOCATION OF CEREMONY
(CHECK ONE AND ~CIFY)
o CITY OF cYf'OWN OF 0 VILLAGE OF
SPECIFY~A-AO i 1\J6l1j; ~
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
NAME (PRINT)
SIGNATURE~