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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 Peter M~~ristie Ste~DR~D.t J~NAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
CITYrrOWN Wappinqer
~~~:~c; 1368 .
~5~I:J~R 111
.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Harm~I~~E Leigh Ja~~~~fsURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 088 70 3892
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY!1"I TOWN D VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 1668 Apt. 8c Route 9 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES l!"j NO
3. A. AGE 33 3B. DATE OF BIRTH 09 / 18 / 1976
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Stephen
(OPTIONAL - SEE REVERSE) 054 74 8522
D. SOCIAL SECURITY NUMBER --
12 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY r!l TOWN D VILLAGE
~~~CIFY Wappinqer
D. STREET ADDRESS 1668 Apt. 8c Route 9
ZIP 12590
DYES tJ NO
/1'977
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 32 3B. DATE OF BIRTH 02 ,.,,07
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION NPO
B. TYPE OF INDUSTRY OR BUSINESS Nuclear Power
5 PLACE OF BIRTH Dearborn Heights. Mi
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Peter Christie Stephen III
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Janet Stewart
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Scheduler
B. TYPE OF INDUSTRY OR BUSINESS Mid Hudson Medical
15. PLACE OF BIRTH Pouqhkeepsie, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Charles Edward Jakubek
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mary Sue Boshart
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
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
c. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
(3) D ANNULMENT (2) D 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
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
21. SIGNATURE OF GROOM~
D D 1ST D D
D D ~D D D
D D 3RD D D
D D 4TH D D
and belief that the information I provided is true and that I declare that no legal impediment exists
. SIGNATURE OF BRIDE~ ~/'YL-1J of, O,:;.,b~_
USE 1rRENT NAM6'
if'x-- DATE 09/18/2009
f S
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OA CITY CLERK ~
This license authorizes the marrLage in New York State of the bride and groom named above by any person authorized
Relations Law ~11to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 09/18/200
I....- .-J MAII.lfi{> ~qOIIFlE9.Se AM
-v- LU IVI aal sh Rd, Wappingers Falls, NY 12590 01 :03PM 09
STREET CITY/TOWN STATE ZIP
~~~A~~Ri~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED AeOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. .....--. 9 D OTHER, SPECIFY
29. OFFICIANT R. J q
NAME (PRINT) ."'-.
by New York Domestic
MONTH
YEAR
11
17 2009
19
2009
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNrvOllco\cs ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF J2\ TOWN OF D VILLAGE OF
SPECIFY (;:0-...>-+ ~.s '\; k.\ ~
IE...
NAME (PRINT)
SIGNATURE~
NAME (PRINT)