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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Wa\lne FrJwarrJ DeHart
J'MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:f~ 1368 .
~5~:J~R 116
1 . A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 127 56 8328
D. SOCIAL SECURITY NUMBER _ __ - __ - ----
2. RESIDENCE A. NY B. nlJtchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREET ADDRESS 30 Tang lewood Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
3. A. AGE ~n 3B. DATE OF BIRTH O? / 19 / 1973
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Audio Video Technician
B. TYPE OF INDUSTRY OR BUSINESS Communications
5. PLACE OF BIRTH Poughkeepsie. NY
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Wallace Earl DeHart
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gloria June Ruger
B. COUNTRY OF BIRTH U S A
8. NUMBER OF THIS MARRIAGE 2
9. ~~~~~~{R~FR~~AE~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) C'1 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 08/ 22 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 0 NO
10. 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
08/22/2008 Poughkeepsie. Nv C'1
DEATH
o
(2) 0 DEATH
2008
YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
--1
L)lnn Ann Jimenez
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Fllrni::l
c. SURNAME AFTER MARRIAGE ne Hart
(OPTIONAL. SEE REVERSE) 105 60 9153
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 30 T analewood Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
/14 /1'973
DAY YEAR
11. A. FULL NAME
13. A. AGE 36
05
MONTH
36. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Registered Nurse
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Plattsburah. NY
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Ronald Paul Furnia
. 6. COUNTRY ~F BIRTHU S A
17. MOTHER
A. MAIDEN NAME Harriett Adele Smith
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) c1 DEATH
c. DATE LAST MARRIAGE ENDED? 02 / 01 / 2007
MONTH .JJAY' .. ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES r"J 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
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say
as to my right to enter into the rr
21. SIGNATURE OF GROOM~
USE
23. SUBSCRIBED AND SWORN TO/AFFI 0 BEFORE ME
SIGNATURE OF TOWN OR CITY CLE K ~
This license authorizes the marriage in New ork 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 onl for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Joh C. Masterson
{ ~ TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~ c: DATE 10/02/2009
'-v-' MAI~~~FaE ush Rd, Wappinaers Falls, NY 12590 02:56~~ 10 03 2009 12 01 2009
STREET CITYITOWN STATE ZIP
~~:R~~RT~~J IO~O~~~N~Z:R- 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M . AY YEAR 0 IiO RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. . p II / 3 ). 9 0 OTHER, SPECIFY
~~I~n~~~ l2o}3e.,e.:r (J. 5(VJi-ft... TITLE ?A-~6i
SIGNATURE~ ~ <4 li'\ _ ~ DATE II/; ~/oe;
M~ING ADDflF~~. r I ../-:..f-I= , I
'-1~ 3 fYK;UJ1 o'T. 1-/(J,lA/1, f'Jy 125)-1
STREET CITY/TOWN ' STATE
30. WITNESS TO CEREMONY
NAME (PRINT) ~fi::
o
o
1ST
2ND
3RD
o
o
o
22. SIGNATURE OF BRIDE ~
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY j)~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~. CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ?~ h !:aef!'ie
SIGNATURE~