102
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Andre I<~~!pn Ashtol6ulj~~A~E
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
? n 0
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 1 n/ 1 R / ?OOR
MONTH OA Y YEAR
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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 05/04/1 990 Bermud~ . [!' 0 1ST
2ND 10/16/2008 Bermuda [j' 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swe!lr/affirm, Clep.ose and say, that to the best of my knowledge and belief that the information I provided is'
as to my right to enter Into the mar ge state.
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21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
COUNTY Dutchess
CITYrrOWN Wappinger
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1 . A. FULL NAME
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B. BIRTH NAME, IF DIFFERENT
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C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. B~~m! Id a B. (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND
SPECIFY ~t r,p.nr[}p.~
D. STREET ADDRESS POBox GE249
ZIP
xxx-xx-xxxx
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES.tj NO
MO~~ /olP / y1~58
3, A. AGE 51
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION MarinE' Pilot
B. TYPE OF INDUSTRY OR BUSINESS Pllhlir. Tr;::)nsportation
5, PLACE OF BIRTH ~~q~tE /~~~~II~~;T USA)
6. FATHER
A. NAME 1=11[}E'r'lP TIIZO
B. COUNTRY OF BIRTHRermud~
7. MOTHER
A. MAIDEN NAME M;::)ry F Hnllinsid
B. COUNTRY OF BIRTH Rerml U;;::)
8. NUMBER OF THIS MARRIAGE 3
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STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
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11. A. FULL NAME FIRST Np.ttp.rM~j~l::lhpth T~~R~~~URNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Da\lis
c. SURNAME AFTER MARRIAGE 1-1011 ins id
(OPTIONAL. SEE REVERSE>
D. SOCIAL SECURITY NUMBER 1 58-54-4694
12. RESIDENCE A. NY B. nr Itr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN Ii!!! VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS Unit 19-1 F Vandidoort Dr
ZIP 12524
~YESDND
/"f95R
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 5? 3B. DATE OF BIRTH 10 /?1
MONTH OA Y
14. EMPLOYMENT
A. USUAL OCCUPATION Thpr::lpi!=;t
B. TYPE OF INDUSTRY OR BUSINESS Human Services
15. PLACE OF BIRTH Bridaeton, N J
(CITY, S'i"ATE / COUNTRY IF NOT USA)
16. FATHER .
A. NAME Frlrlie n;::)vi!=;
, B. COUNTRY OF BIRTH USA
17. MOTHER .'.
A. MAIDEN NAME Sarah Pennington
B. . COUNTRY OF BIRTH USA
1~. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF. PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
001
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~ DEATH
C. .DATE LAST MARRIAGE ENDED? 09 / 24 / 1985
MONTH , 'pA Y ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES I!f 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
o
o
o
USE C R
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 w~hfn 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
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NAME (PRINT)
DATE 09/04/2009
by New York Domestic
TIME
MONTH
YEAR
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STREET
I CERTIFY THAT I SOLEMN IZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATE
DATE 09/04/200
rs Falls NY 12590
N STATE ZIP
27. TYPE OF CEREMONY . /'
00 RELIGIOUS 1 a;;rGIVIL
9 0 OTHER, SPECIFY
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AM
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09
05
2009
11
03 2009
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
PP;Cilvh
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFI..AJ~ fY'...IJ~ ~