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COUNTY Dutchess
CITYrrOWN \^'apping8T
DISTRICT . .
~~~I~~~R 1368
NUMBER Q2
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Matt~~ David J~~~~~RNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kath8~~E Carol Pe~~mURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. sYS~~~rt.~~~~t~W~~~sJ)ackson
D. SOCIAL SECURITY NUMBER n47-7R-Q~Q1
12. RESIDENCE A.N~STATE) B. Dlt!tb~ss
C. CHECK ONE 0 CITY eJ TOWN 0 VILLAGE
AND \^/ .
SPECIFY arpmgAr
D. STREET ADDREss141 Wirlmp.r Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 23 3B. DATE OF BIRTH ~~TH ~~AY -1 ~~~
14. EMPLOYMENT
A. USUAL OCCUPATION StLldent
B. TYPE OF INDUSTRY OR BUSINESS I p.high I Jniver~ity
15. PLACE OF BIRTH \^,::ItArhllrv r.nnn
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Brllce Eric Pearson
'B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME FIIF!n r.::Irnl (.;p.n~lp.r
B. COUNTRY OF BIRTH I J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
o SOCIAL SECURITY NUMBER 100 76 667Q
2. RESIDENCE A. NV B. n, ,~,",heS8
i\lTATE) ~,
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND
SPECIFY East Fishkill
D STREET ADDRESS 169 Benton Moore Rd ZIP 1 ?&:i3~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES olZI NO
MO~ / Dip / y1iB'1
3. A. AGE 25
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Pimn State Ilni\lersity
5. PLACE OF BIRTH 0", ,nbkaan",ia MV
lcl~;"MI\'r~ lC"oUIn'I'lV Il" NdTlJSA)
6. FATHER
A. NAME W31ter Edg3r .J3ckson Jr.
B. COUNTRY OF BIRTH IJ S .f;;
7. MOTHER
A. MAIDEN NAME Patricia Ann Bohlin
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
DEATH
o
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST- MARRIAGE ENDED?
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
1ST
2ND
3RD
4TH
I duly swear/affirm. depose and
as to my right to enter into the
21. SIGNATURE OF GROOM~.
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
edge and belief that the information I provided is true and that I declare that no legal impediment exists
~~
USE CURRENT NAME
w
en
z
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o
::;
EC 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 within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
o " checked, this license is to be used only for the urpose of a second or subsequent ceremony.
,-I'-., 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) I~~~
SEAL SIGNATURE. . - DATE OR/? 1/?nO
MAILING ADDRESS
'-.t-I ~ t\11irldlF!hll~h Rrl W::Ir~in&Wr~ F~lIs NY 12590
STRE ' ITYIT N !nATE ZIP
~~~R~~RTr~~ 10~0~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED.
10
20 2009
DATE 08/21/2009
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
AM
02: 18PM
08
22
2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY (hjcle5>
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
10 CIVIL
o CITY OF ();I TOWN OF 0 VILLAGE OF
SPECIFY <=" p...s, ~ ~; <.,. h k ~ \ ,
, \
30. WITNESS TO CER~ /) 1 I
~/1~1Y)tJ.~ 4. ~d/l JI)
NAME (PRINT) Y."." ~ .:.;.; ~ _A. J (..}) _ n ,_
SIGNATURE. ~~ ~ ~
31. WITNESS TO CEREMONY
NAME (PRINT) ..s.~p h 6.,\ 1 ; 2. ") I
SIGNATURE.
~ ...c.b~