130
STATE OF NEW YORK I" STATE FILE NUMBER I
COUNTY Dutchess (THIS SPACE FOR STA TE USE ONL Y)
CITYrrOWN Wappinger DEPARTMENT OF HEALTH
DISTRICT 1 368 AFFIDA VIT, LICENSE and
NUMBER
REGISTER 130 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Josh Richard McCarty 11. A. FULL NAME Nicole Anne Hauser
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE McCarty
(OPTIONAL. SEE REVERSE1603-32-0528
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A, NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK Ot/Ii . 0 CITY U TOWN 0 VilLAGE
~~~CIFY wappmger
D. STREET ADDRESS4U2 jJopula tjlva.
1 Lbl:lO
ZIP
MONTH
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 121-68-0886
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY' B. Dutchess
(STATE) (COUNlY)
C. CHECK ONE 0 CITY 'C TOWN 0 VilLAGE
AND W .
SPECIFY applnger
STREET ADDRESS 402 Popula Blvd.
12590
YES'6 NO
/1983
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. .AGE 21 3B. DATE OF BIRTH 03
14. EMPLOYMENT
A. USUAL OCCUPATION Sale Associate
B. TYPE OF INDU~TRY O,R BUSI~!iS. RadiO ShacK
15. PLACE OF BIRTH ~an LUIS UOISpO, Ga
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Thomas J. Houser
'B. COUNTRY OF BIRTHU S A
17. MOTHER. .
A. MAIDEN NAME Joan M. Fitzgerald
B. COUNTRY OF BIRTHU S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D100RCE CIVil ANdULMENT
DE~TH
4. EMPLOYMENT
A. USUAL OCCUPATION EMT
B, TYPE OF INDUSTRY OR BUSINESS Mobil Life Support Services
5. PLACE OF BIRTH Auburn, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John F, McCarty
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jacqueline Pilat
B. COUNTRY OF BIRTH France
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. " - YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
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20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
0 0 1ST 0 0
0:' 0 0 2ND 0 0
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23. SUBSCRIBED AND SWORN T IAF IRMED BEFORE ME
SIGNATURE OF TOWN OR CI ERK ~
This license authorizes the marriage in New. York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11to 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 urpose of a second or subsequent ceremon ,
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jo .
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
\-. .-J MAII,.J,NG tl;lD1lFlESS AM 11 14 2009 01 12 201 0
-v- LU M CCI 02:05PM
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
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SIGNATURE~
YEAR
1 ;i CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY I1r~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF P(TOWN OF 0 VILLAGE OF
SPECIFY a; 1f;!J/JI.rV(9i:=,,<