056
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
STATE OF~NEWdYORI(
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
E.
MIDDLE
Dutchass
Wappingar
116R
'l6
COUNT'I.
~OWN
DISTRICT
NUMBER
REGISTER
NUMBER
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M. Spragna
MIDDLE CURRENT SURNAME
Larua
FIRST
Walkar
CURRENT SURNAME
11. A. FULL NAME
Eric
FIRST
1. A. FULL NAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wa 1 ka r
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 111- 5 8- 6434
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN KI VILLAGE
AND
SPECIFY TJ~ppingpr!': FR11!':
D. STREET ADDRESS 2 Franklin St.
~~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 110- 58-8275
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
AND
SPECIFY Wappingers Falls
o STREET ADDRESS 2 Franklin St. ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3 A. AGE 34 3B.DATEOFBIRTH Sent. / 05 /1965
M1iNTH DAY YEAR
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [1J: YES 0 NO
13.B. DATE OF BIRTH April /04 /1976
MONTH DAY YEAR
24
13. A. AGE
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION
A. USUAL OCCUPATION Cashier
B. TYPE OF INDUSTRY OR BUSINESS Burlington Coat Factory
15. PLACE OF BIRTH (CITYq~Jjcou~~~lf~fus~ew York
Cook
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....
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B. TYPE OF INDUSTRY OR BUSINESS Home Town Buf f e t
5. PLACE OF BIRTH Mathatten New York
(CITY, STATElCOUNTRY IF NOT USA)
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a 1-15
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16. FATHER
6. FATHER
A. NAME Herbert Walker
B. COUNTRY OF BIRTH TT!=\A
7. MOTHER
A. MAIDEN NAME Kay FranC'es Wi 11 i ams
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME !=\.<Imna1 .TRmes !=\prRgn2 TTT
B. COUNTRY OF BIRTH TT!=\ A
17. MOTHER
A. MAIDEN NAME Dorrhy .Tean T..<I!':hpr
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE Fir s t
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED.BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
(2) 0 DEATH
131 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) [} DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) L: DEATH
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES = 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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [} YES :J NO
10. 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
r
LJ --,
0 LJ
0 :J
1ST
2ND
3RD
4TH
I. being duly sworn. depose and
as to my right to enter into the m
21. SIGNATURE OF GROOM.
c
, C
,.
May 'l, 2000
by New York Domestic
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any p
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK TATE ONLY.
:J If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ } ::~~~;,~~~~~~ Town r.1 ~Tk 25. A. SOLEMNIZATION PERIOD BEGINS
{SEAL SIGNATURE.~'l~~.J..;(. DATE 'l/'l/no TIME MONTH YEAR MONTH DAY
MAILING ADDRESS AM
'-,,-I ~~E~nv 374 Wappjngersclf;~i, NY sTb~590 .15 PM 5 6 00 7 4 00
~~~R~~~RT~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY 2B. PLACE WHERE MARRIAGE OCCURRED
~~~ ~~~E~T A:H~V~I~~ r~6 TIME MO. DAY YEAR 0 C RELIGIOUS A. STATE NEW YORK B. COUNTY J),^\t'.~
PLACE INDICATED. 9 C OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TOWN OF "VILLAGE OF
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
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TITLE .J..~\c... aC!L- ~~~
DATE ~ / rs /00
,
SPECIFY
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