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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Keith Lawrence Miller, JR.
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWJI! Wappinger
DISTRICT 1 36tl '
NUMBER
REGISTER 2
NUMBER
1. A. FUll NAME
FIRST
Q.
IQ
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl. SEE REVERSEl()43-76-8813
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE).L. (COUNTY)
C. CHECK ONW 0 CITY LJ TOWN 0 VILLAGE
AND .
SPECIFY applnger
D. STREET ADDRESS 37 I- Alpine Urlve ZIP 1 LOl:JU
ot.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
3. A. AGE 25 3B. DATE OF BiRTH 02 / 16 / 984
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Correctional Officer
B. TYPE OF INDU~RY QR BUSIN~S Corrections
5. PLACE OF BIRTH uanoury, L;t
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Keith Lawrence Miller
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Susan Frances Robson
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. ~~~~L?~~RM6'f~~~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DE6TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMEHT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Julianne Marie Cuatt
~
11. A. FUll NAME
FIRST
CURRENT SURNAME
MIDDLE
B. BIRTH NAME (MAIDEN NAME)'fJIQlrERENT
C. SURNAME AFTER MARRIAGE I er
(OPTIONAL. SEE REVERSE>1 31- 70- 7 360
D. SOCIAL S~CltRJTY NUMBER
12. RESIDENCE A.N Y Buutcness
(STATE).L (COUNTY)
C. CHECK ~ k 0 CITY D TOWN 0 VILLAGE
AND Ijee man
SPECIFY 4 17 Cia Hili Rd t 2540
D. STREET ADDRESS PP ZIP
.,
E. IS RE~~NCE WITHIN LIMITS OF CITY OR INCORPORA'B~ VILlAGE? D3 0 YE~ )J,~O
13. A. AGE 3B. DATE OF BIRTH L:.. E
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
Education
B. TYPE OF INDijSlRY OF! flUSINESS ".
15. PLACE OF BIRTHMoum "ISCO, I'IY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER .
A. NAME John FranCIS Cuatt, Jr.
U::iA
B. COUNTRY OF BIRTH
17. MOTHER J M' L
A. MAIDEN NAME oyce ane ayman
U::iA
B. COUNTRY OF BIRTH I
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A"O'ULMENT
D~TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. -.- YEAR
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) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
nowledge and belief that e information I provided is tru
29. OFFICIANT
NAME (PRINT)
TITLE
~
SE RRE
23. SUBSCRIBED AND SWORN TOI FFIRMED 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 person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o " checked, this license Is to be used only for the purpose of a second or subsequent ceremony.
,-.I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masterson
{SEAL SIGNATURE~' DATE 01/14/2010 YEAR
'-v-' MAI~'O'~r88ie ush Rd, Wappingers Falls, NY 12590
STREET CITYITOWN STATE ZIP
~~~R~~RT~~~ 'o~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME AY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. PM 9 0 OTHER, SPECIFY
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
CITYITOWN
STATE
nru....~OA In'al?lV\A\
o 0
o 0
o 0
o 0
nd th~t I declare that no Ie al impediment exists
t
DATE
by New York Domestic
YEAR
03
15 2010
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~