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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:f: 1368 .
~~~~J~R 144
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William Georae Distler
MIDDLE CURRENT SURNAME
r
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
SUPPLEMENTAL FILE
FROM THE BRIDE
Courtney Elizabeth Harding
MIDDLE CURRENT SURNAME
-.J
Lo
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME)O DIFFERENT
C. SURNAME AFTER MARRIAGE istler
(OPTIONAL. SEE REVERSE()77 -70-77 4 7
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A.NY B.uutchess
(STATE).L (COUNTY)
C. CHECK QIiE. 0 CITY'U TOWN 0 VILLAGE
~~~CIFYvvappmger
11 L :smltntown Road
D. STREET ADDRESS
B. BIRTH NAME, IF DIPFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEb89 58 6209
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..o TOWN 0 VILLAGE
~~~CIFY Waooinaer
D. STREET ADDRESS 112 Smithtown Road ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES....O NO
3. A. AGE48 3B. DATE OF BiRTH 11 /14 /1961
MONTH DAY YEAR
12524
ZIP
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORA8~ VILLAGEps 0 YjS7 fO
13. A. AGE38 3B. DATE OF BIRTH
MONTH DAY YEAR
14. EMPLOYMENT .' J\' t
A. USUAL OCCUPATlo~dmimstratlve sSlstan
t-Inanclal Services
B. TYPE OF IND~TRY ~ BUS~E~
15. PLACE OF BIRTH ew urg, y
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER .
A. NAME William Wesley Hardmg
'B. COUNTRY OF BIRTHU S A
4. EMPLOYMENT
A. USUAL OCCUPATION UPS Driver
B. TYPE OF INDUSTRY OR BUSINESS Shipping
5. PLACE OF BIRTH Beacon. NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Charles Francis Distler
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dorothv Elizabeth Brady
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
17. MOTHER
A. MAIDEN NAME Carol J\nn Vellake
B. COUNTRY OF BIRTHU S A
L
18. NUMBER OF THIS MARRIAGE
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9, PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DI1VORCE CIVIL Ai'WULMENT
100 u
....
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DlvoRC13 (3) D1^~NULMENT 19~~ DEATH
C. DATE LAST MARRIAGE ENDED? 02 / 09 / 2009 C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONT~ DAY"- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY. IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITYICOUf'oll):. STATEI\XlUNI'\Y, IF NOT USA) S,"F SPOUSE
02/09/2009 Dutchess County. Ny t5 0 1ST 06/14/1999 Orange l,;oumy, NY 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
owledge and belief that the information I provided is?!,. and that I declare th~at no legal impediment eXists
22. SIGNATURE OF BRIDE~ ll<frt lArZ ~-,
~CURRENT NAME /28/2009
DATE
D1jTH
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the
as to my right to enter into the mam state
21. SIGNATURE OF GFlOOM. I,)J,
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New y, k State of the bride and groom named above by any person authorized by New York Domestic
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 OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Mas erson
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE 12/28/200
MAILING ADDRE~ AM 12 29 2009 02 26 2010
'-v-' 20 Midal ush Rd. Wappingers Falls, NY 12590 01:40pM
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 0 RELIGIOUS 1 CIVIL
DATE ANO AT THE TIME AND
PLACE INDlC 9 0 OTHER, SPECIFY
YEAR
29. OFFICIA
NAME (PRI
26. PLACE WHERE MARRIAGE OCCU~ _
A. STATE NEW YORK B. COUNTY([1'" c ,-wq
C. LOCATION OF CEREMONY
(CH~NE AND SPECIFY)
~ITY ~ TOWN OF 0 VILLAGE OF
SPECIFY 1'6 w€.:tI a~s rs
SIGNATURE ~
MAILING A"ES
" Cl'f:)
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) · V \'\\,\ "A Q " ~""""
SIGNATURE~ .. \I.... ~
DOH.98 (0312006)
NAME (PRINT)
SIGNATURE~