No preview available
039 \.- W I- .. I- <f) I- Z W U) W lD 9 => o r <f) Z o ;:: .. a: I- U) a W a: W CJ <( a: ~ l- S; <( C w - "u. Su. ~<( Z ;: g >- I- U Zi.z ~~8 w :i!i€~ !:; I-WZ ..... ~d~ () ~~g u:: Z ~lL i= o a: w () U) >- .. ....."--' 0 ~lJ') Ou Z:J~ COUNTY . XIltY/TO\llN DISTRICT NUMBER REGISTER NUMBER STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM ~ In ST A TE fiLE NUMBER (THIS SPACE FOR STATE USE ONLY) nIl t C'np !':!': tJ!'lppinepr 13hR 39 / ~/" /~o L 0 SUPPLEMENTAL FILE FROM THE BRIDE Dawn M. Wimberly FIRST MIDDLE CURRENT SURNAME L A. FULL NAME Ronprt FIRST CURRENT SURNAME Co. TitkR MIDDLE ,," A FULL NAME "" N B BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL" SEE REVERSE) o SOCIAL SECURITY NUMBER n'i 1- 'i n R? 'i 2 2" RESIDENCEA. New Yor-k B nlltC'np!,:!,: (STA~r (ebUN"'R') C CHECK ONE 0 CITY Il!I TOWN 0 VILLAGE ~~~CIFY Fi !':nki 11 o STREET ADDRESS ? 1F. V!'lnHorn Ci rcle ZIP 12508 E" IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Xl NO 3" A AGE ~"- 36 DATE OF BIRTH Sept. / 23 / 60 MONTH DAY YEAR MONTH B BIRTH NAME (MAIDEN NAME), IF DIFFERENT C SURNAME AFTER MARRIAGE Tit ka (OPTIONAL" SEE REVERSE) 0" SOCIAL SECURITY NUMBER 0 q q - 7 4 -9 21 9 12. RESIDENCE A, New York B" Dutchess (STATE) (COUNTY) o CITY ~ TOWN 0 VILLAGE Fishkill 0" STREET ADDRESS 21 F. VRn Horn Circle C, CHECK ONE ANa SPECIFY ZIP 12508 E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO / 14 / 74 DAY YEAR 26 13"6 DATE OF BIRTH Jan 13" A, AGE 4. EMPLOYMENT 14" EMPLOYMENT A. USUAL OCCUPATION MRnllfRcturing 6 TYPE OF INDUSTRY OR BUSINESS TRM 5" PLACE OF BIRTH M.ann::!rrJ'ln NpUT York (CITY, STATE/COUNTRY IF 1.iOT USA) 6" FATHER A USUAL OCCUPATION Manufacturing B" TYPE OF INDUSTRY OR BUSINESS T BM 15, PLACE OF BIRTH Anaheim. California (CITY, STATElCOUNTRY IF NOT USA) 16" FATHER A NAME Ronprr T 6 COUNTRY OF BIRTH 7. MOTHER A" MAIDEN NAME r.on!':rJ'lnC'P T. Npgli.g Titk.g TTSA A NAME Jerry W. Wimberly B. COUNTRY OF BIRTH USA n MOTHER A MAIDEN NAME Theresa M. 6 COUNTRY OF BIRTH USA Ritter B. COUNTRY OF BIRTH TTSA 8" NUMBER OF THIS MARRIAGE 2nd 18, NUMBER OF THIS MARRIAGE 1st 9" PREVIOUS MARRIAGES A" NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT 1 19. PREVIOUS MARRIAGES A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT DEATH DEATH B. HOW DID LAST MARRIAGE END? (3) tx 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? N rm / 1 q /1 q q (j C, DATE LAST MARRIAGE ENDED? / / MONTH DAY YEAR MONTH DAY 0" ARE ANY FORMER SPOUSE(S) ALIVE? XXfES 0 NO 0" ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO 10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20" IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM (MONTH, DAY, YEAR) (CITY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE 1ST --1Jj19/96 Dutchess Co, NY 0 Il!I 1ST 0 0 o 0 2ND 0 0 o 0 3RD 0 0 o 0 4TH 0 0 and belief that the information I provided is true and that I declare that n~legal impediment exists 22, SIGNATURE OF BRID~ ~ I d/~,t ~ USE CUR~ NAME J Town Clerk DATE 4/14/00 YEAR 21. SIGNATURE OF GROOM ~ w en z w () ::i 23. SUBSCRIBED AND SWORN TO 8EFORE 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 person authorized 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 O~RK 25 A SOLEMNIZATION PERIOD BEGINS } NAME(PRIN~) L ..EJ~~,. ~den, TQwClerk {SEAL SIGNATURE ~ ~{lLLL\ ~ ~k.1,^,rJll DATE 4/14/00 TIME MONTH DAY YEAR MAILING ADD RES AM '-v-' PSTRQE~ Rox 3?L.. tJ;::!ppingp.r~ITy~gwP S. NYsrtTP90 ZIP PM 04 I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~~~sM~~~~g~B~V;~N PTEHRE TIME MO DAY YEAR oM RElIGIOUS DATE AND AT THE TIME AND PLACE INDICATED Sol.. 00 90 OTHER, SPECIFY 00 by New York Domestic MONTH YEAR 15 00 06 13 28" PLACE WHERE MARRIAGE OCCURRED 10 CIVIL A" STATE NEW YORK B. COU'JTY ~l'\Q.SJ C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF 0 TOWN OF 1<1( VILLAGE OF 29. OFFICIANT ~ tt ~ M NAME (PRINT) €u. ..;.II(2('d(O" . QC'\.Ic~ SIGNATURE~ ~.~'-13.1T(~ Z MAILING ADDRES q 1'1...:51' ~r Ave. "5vu'\'h d.v w.....Prf (\3 l ('So STREET CITYiT N 30 WITNESS TO CEREMONY TITLE .'1 iY"l\s'h::. 5- c--oo DATE SPECIFY l-)nf1fVl'\~~ FeUIS FCA.I\C; t N euJ YOl \( TATE NAME (PRINT) SIGNATURE ~ DOH-98 (I 1/98) NAME (PRINT) SIGNATURE ~