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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST KYJ~D!VlatthE'\^' qbW~T SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c~ 1 368 '
~5~I~l~R 11 5
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
MAli~~::J f)::Jwn White
MIDDLE CURRENT SURNAME
-.l
11, A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)
o SOCIAL SECURITY NUMBER nQfi-7 n-~n 1 n
2. RESIDENCE A. Nt-rATE) B. Qbb~e'S'S
C. CHECK ONE 0 CITY I2l TOWN 0 VILLAGE
AND
SPECIFY Hyrlp. P::Jrk
D. STREET ADDRESS 113 South Ouaker Lane ZIP 12538
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 24 3B. DATE OF BIRTH MO!J~ / D9-f / ylA~85
4, EMPLOYMENT
A. USUAL OCCUPATION Eler.tri~i::Jn
B. TYPE OF INDUSTRY OR BUSINESS C':orredions
5. PLACE OF BIRTH ~~!il~E~~OUN~RYIF NOT USA)
6. FATHER
A. NAME RIIc:c::.p.11 r.1::lrk
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME Alir.p. OC':onnor
B. COUNTRY OF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE CI::Jrk
(OPTIONAL, SEE REVERSE)
D. SOCIAL SECURITY NUMBER 071- 70-6741
12. RESIDENCE A. NY B. [)\ Jtr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY !!ZI TOWN 0 VILLAGE
~~~CIFY Hyde Park
0, STREET ADDRESS 113 South Quaker Lane
ZIP 12538
DYES~NO
AQR4
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?A 3B. DATE OF BIRTH 1 n ~1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Assistant Manager
B. TYPE OF INDUSTRY OR BUSINESS Banking
15. PLACE OF BIRTH Carmel NY
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME ArthlJr SAwell White
'B. COUNTRY OF BIRTH U S A
17. MOTHER
A. MAIDEN NAME Brenda Lee Hoystradt
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
w
en
z
w
(J
:i
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the Information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the m n ge state 1!1y - -
21, SIGNATURE OF GROOM ~ . ~.. 22. SIGNATURE OF BRIDE ~ . t 1m.J... j), (,1 JItIhL
. USE A NT NAME ,. USE C~NT ~
23. SUBSCRIBED AND SWORN TO/AFFIRMED. BEFORE.ME , 1 % 1/2009
SIGNATURE OF TOWN OR CITY CLERK ~ 'v DATE
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 ~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
~
{ SEAL }
'-v-'
NAME (PRINT)
YEAR
MONTH
YEAR
DATE 1 % 1/200
ers Falls NY 12590
N STATE ZIP
27, TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
AM
03:02PM
10
02
2009
11
30 2009
in
ITYIT
26, SOLEMNIZATION OCCURRED
TIME MO, DAY YEAR
1~~'l5 A~ 10 ocr QaJ<?
1~IL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER,
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTY bvTc.He 55
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
29, OFFICIANT
NAME (PRINT)
TITLE
mA--RR-l~ OC~lcf{(
r (lh ( ~,,9
SPECIFY
I,\JAPP )tJc;,~L
DATE
STATE
31. WITNESS TO
NAME (PRINT)
SIGNATURE~