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COUNTY Dutchess
CITYfTOWN Wappinaer
~~J:fRT 1368 .
~~~I~~~R 41
~ I '"' I E: ur I~I; vv ,un"
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David Alan Mann
MIDDLE CURRENT SURNAME
FIRST
(TH/S SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Laura Kimberly Somers
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEb67 62 1278
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A NY B. Oranae
(STATE) (couNm
C. CHECK ONE D CITY D TOwNIO VILLAGE
~~~CIFY Maybrook
D STREET ADDRESS 418 Rakov Rd. ZIP 12543
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? tJ YES D NO
3. A. AGE 45 3B. DATE OF BIRTH 09 / 15 /1963
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mann
(OPTIONAL. SEE REVERSEb72_62_3065
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BOrange
(STATE) (COUNTY)
C. CHECK ONE D CITY D TOWN"6 VILLAGE
~~~CIFYMaybrook
D. STREET ADDRESs418 Rakov Rd. ZIP 12543
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? "6 YES D NO
/1'2 .A'968
YEAR
13. A. AGE40
3B. DATE OF BIRTH
07
MONTH
DAY
4. EMPLOYMENT
A USUAL OCCUPATION Custodian
B. TYPE OF INDUSTRY OR BUSINESS School District
5. PLACE OF BIRTH Newburah, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME Edward Alan Mann
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Shirley Francella Dolson
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Medical Secertary
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTHPoughkeepsie, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Edward Somers
'B. COUNTRY OF BIRTJ:J. S A
17. MOTHER
A. MAIDEN NAME Marilyn Lastrom
B. COUNTRY OF BIRTHU S A
16. NUMBER OF~HIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) !1 DIVORCE (3) D ANNULMENT
C. DATE LAST MARRIAGE ENDED? 10 / 21 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? &YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
10/21/1999 Goshen, NY D !1 1ST
D D 2ND
D D 3RD
D D 4TH
that to the best of my knowledge and belief that the information I provided is true a
estate.
DEATH
o
19. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) D DEATH
1999 '
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT (2) D DEATH
/ /
. ~ YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and
as to my right to enter into the
21. SIGNATURE OF GROOM~
D 0
D D
D D
D D
Ie al impediment exists
U E CURRENT
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 ~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)
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 05/15/2009
"-- -.J MAIj,JIiG f\Df 1 0 39 AM
-v- ;LU M in ers Falls, NY 12590 : 05
STREET CITYfTOWN STATE ZIP PM
~~~RJ~RT~~J 'o~O~~~N~ZE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY . /
SONS NAMED ABOVE ON THE TIME M . AY YEAR 0 D RELIGIOUS 1121\CIVIL
DATE AND AT THE TIME AND "
PLACE INDICATED. 9 D OTHER, SPECIFY"
DATE
by New York Domestic
MONTH
YEAR
16
2009
07
14 2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COu~vr{~J"t,1;.s: ("
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF .P( TOWN OF D VILLAGE OF
SPECIFY /1/M Pj/l/&G.e
NAME (PRINT)
SIGNATURE~