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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
DOUiQtQC Elwin ~~~ SURNAME
1ST 01/29(2009 Goshen, NY [9" 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
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
as to my right to enter into arnage state.
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
7 us
23. SUBSCRIBED AND SWORN TO/AFFIRMED B FORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marria e in New rk 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 " 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
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c: 1368 .
~5~~J~R 107
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER DaD 50 1170
2. RESIDENCE A. NV B. 1\, .+...hess
(STATE) '1t:~
C. ~~gCK ONE 0 CITY l;ll TOWN 0 VILLAGE
SPECIFY Wappinger
D STREET ADDRESS 25 Lakeside Dri\le ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES eJ NO
MO~ / rfM) / v1.a55
3. A. AGE 54
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Self Employed
B. TYPE OF IN'DUSTRY OR BUSINESS Home Impro\lement
5. PLACE OF BIRTH ~'1~W~ 'i*
(I , A I bUN V IF NOT USA)
6. FATHER
A. NAME Elv:in Eugene Booth
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME M81ry P81uline E\lancho
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE ?
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES wHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01/ 'J~ / 'Jn09
MONTH Di(If' ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? ClI'\'ES 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
W
en
z
W
()
::::i
~
{ SEAL }
'-v-I
NAME (PRINT)
r
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FIRST~.nne M~~J.Oblis8 S\~fjM~t~~~E
.J
11. A. FULL NAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~:g"'~~~~t~~~~~s~ 0 oth
o SOCIAL SECURITY NUMBER 044-58-4071:\
12. RESIDENCE A. N~STATE) B. D~b~SS
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS?!=; I ::Ikp.!=:irlp. nrivp. ZIP 1 ?!1!=!O
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
Q~TH /()~AV /-f ~8J
13. A. AGE 42
14. EMPLOYMENT
A. USUAL OCCUPATION Project Manager
B. TYPE OF INDUSTRY OR BUSINESS IT
15. PLACE OF BIRTH \lernon CT
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
3B. DATE OF BIRTH
A. NAME Ch.rlei CI.rence S'A1eetland
'B. COUNTRY OF BIRTH I I S A
17. MOTHER
A. MAIDEN NAME lanine Rnhp.rt::l f\II::Irip. r.h::lion::llu'!
B. COUNTRY OF BIRTH E ra n ~P.
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (,
MONTH DA V 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
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRV. IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
iment exists
DATE O!=!/110DD!=!
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
01 :56PM
2009
11
10 2009
09
12
TATE
27. TYPE OF CEREMONY
o Ij RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY OiG\f\5e
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF III TOWN OF 0 VILLAGE OF
SPECIFY Q,mLlJc.tll
29. OFFICIANT
NAME (PRINT)
TITLE ~~ 'fI\1"")~(
DATE oq - 2~ "0'1
SIGNATURE ~
MAILING AClQ.8liSS i '
5a'i~ ~~\).,,(.
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) ~5.........
SIGNATURE ~ ""-
n-"lt\("
~r~~
HI .~ ~
STATE ZIP
31. WITNESS TO CE~O~Y I
NAME (PRINT) ...::::>-+ ~ '"' Q..1"\
SIGNATURE~