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COUNTY Dutchess
CITY/TOWJII Wappmger
DISTRICT 1 368 '
NUMBER
REGISTER 126
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas Robert Alexander
MIDDLE CURRENT SURNAME
r
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
I
.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Diane Allyson Johnson
FIRST MIDDLE CURRENT SURNAME
B, BIRTH NAME (MAIDEN NAME). IF ~IFFERENTROOd
C. SURNAME AFTER MARRIAGE A exander
(OPTIONAL - SEE REVERSE082 -52 -8248
D, SOCIAL SIi.CltRvY NUMBER
NY Uutchess
12. RESIDENCE A. B.
(STATE).L (COUNTY)
c. CHECKQIIIF. 0 CITY 0 TOWND VilLAGE
AND vvappmger
SPECIFY 89 vl/ldmer Rd
D. STREET ADDRESS ZIP
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORA'5~ VILLAGE? '>7 0 Y~,.Q ~O
13. A. AGE44 3B. DATE OF BIRTH C ~
MONTH DAY YEAR
14. EMPLOYMENT .
A. USUAL OCCUPATIONFlonst
t-Iowers
B. TYPE OF INDlJQTRY Oll ~USINESS.
t-'ougnKeepsle NY
15. PLACE OF BIRTH '
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Everett M. Rood
. U~A
B. COUNTRY OF BIRTH
1. A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)130-68-694 7
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VilLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 89 Widmer Kd
12590
3. A. AGE 40
1Lb~U
ZIP
.t.
YES I;J NO
/1969
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
03 / 11
MONTH DAY
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Operating Engineer
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH PoughkeepSie, Ny
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas A. Alexander
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joan Marie Lasko
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
17. MOTHER AI' e J. Starr
A. MAIDEN NAME IC
U~A
B. COUNTRY OF BIRTH 2
18. NUMBER OF THIS MARRIAGE
DE8TH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DrORCE CIVIL A~ULMENT
.,
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORfb (3) ~~NULMENT 20lf)~ DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONT"" DAY' ./ YEAR
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
(lvlQIfTJi. D/'JIOYW) P (CITY~NTY, STAT,EICOlLNlRY, IF NOT USA) ,..F SPOUSE
1ST lUI141L Ul::j QugnKeepsle, NY 0 0
2ND 0 0
~ 0 0
o 0
clare thaI no legal impediment exists
9. ~~~~~~J>RMO~R~h'EWf8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT 2B&EATH
c. DATE LAST MARRIAGE ENDED? 05 / 07 /
MONT'4I DAY
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. STATEICOUNTRYNIF NOT USA) SELF SPOUSE
1ST 05/07/2009 Dutchess County, y c5
2ND 0
3RD 0
4TH 0
I duly swear/affirm. dep.ose and saY1 that to the best of my knowled
as to my right to enter into the marrage te. ~#
21. SIGNATURE OF GROOM~~" '
USE IIIR
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CiTy CI-ERKC M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOn . asterson
{SEAL SIGNATURE ~, DATE 11/09/2009 YEAR
'-v-I MA~trltWcrm ush Rd, Wappingers Falls, NY 12590
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 TIM M . Y YEAR 0 0 RELIGIOUS 1 CIVIL
~~6E ~~glt,.~J~E TIME AND ~ 9 0 OTHER, SPECIFY
D'(fTH
YEAR
11/09/2009
DATE
by New Yorl< Domestic
YEAR
01
08 2010
28. PLACE WHERE MARRIAGE OCCU~
A. STATE NEW YORK B. couNT'(ji.~
C. LOCATION OF CEREMONY
(CHECK ONE AND?CIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY Ptft'p,..tA,I..1l.
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~