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COUNTY Dutchess
CITYITOWN WappinQer
~~~:~~ 1368 .
~5~:J~R 146
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Scott Daniel Cashin
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Karen Heather Shipp
MIDDLE CURRENT SURNAME
.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Cashin
(OPTIONAL' SEE REVERSEQ61_72 -167 9
D. SOCIAL SECURITY NUMBER
12. RESIDENCE l~Y BDutchess
(STATE) .L (COUNTY)
C. CHECK ONE P CITY U Ts;lWNLJ VILLAGE
~~~CIFYWappmgers t-alls
D. STREET ADDRE~1 prospect tit z,P'12590
../
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEi,I;J. gO
13, A. AGE30 3B. DATE OF BIRTH 03 )3'3 ~
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE).. 13 72 7049
D. SOCIAL SECURITY NUMBER 'I - -
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOwNOO VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 21 Prospect St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "6 YES 0 NO
08 /17 /1978
MONTH DAY YEAR
3, A. AGE~1
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATIONHair Dresser
B. TYPE OF INDUSTRY OR BUSINES~osmotoI09Y
15. PLACE OF BIRTHMt. Vernon, y
(CITY. STATE I COUNTRY IF NOT USA)
4. EMPLOYMENT
A, USUAL OCCUPATION Safety Engineer
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Richland. Wa
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Ronald Francis Cashin. Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Karen Jeanne Navlor
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
16. FATHER
A. NAMEKeith Sl}lEp
'B. COUNTRY OF BIRn}=ngland
17. MOTHER
A. MAIDEN NAME Diane Peterson
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL ANdULMENT
D~TH
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. ',- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEA'Jli
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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. STATEICOUNTRY, IF NOT USA) SELF SPOUSE
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. STATEICOUNTRY, IF NOT USA) SELF spousE.
21. SIGNATURE OF GROOM~
o
o
o
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
I that to the best of my knowledge and belief that the Information I provided is true and
nage state. / 1
,t'y 2 . SIGNATURE OF BRIDE~
USE CURRE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the rTJ.l)lTlage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform mpfriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
iiil' " checked, this license is to be used only for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25 A SOLEMNIZATION PERIOD BEGINS 25. B. SOLEMNIZATION PERIOD
{ } NAME(PRINT) Jo C. Masterson . . ENDS AT MIDNIGHT ON:
TIME MONTH YEAR MONTH YEAR
SEAL SIGNATURE ~
MAILING ADDRESS 11:31AM 12 31 2009 02 28 2010
'-v-I Mid Ie PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
rf
1ST
2ND
3RD
4TH
I duly swear/affirm. dep.ose and s
as to my right to enter into the m
l~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. cou~)'rr.=ifEgS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY 0; F1 TOWN OF J8C VILLA~E O~
SPECIFYu/4::t.P;II/Bf/.12 ~ 11!UJ'
NAME (PRINT)
SIGNATURE~
nn~_QA 'n~I?fV\R\