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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~1368
~G~~~~R 20
STATE OF NEW YORK
DEPARTMENT OF HEALTH
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Stephen DouQlas Lewis
MIDDLE CURRENT SURNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Renee Lee VanCoughnett
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Lewis
(OPTIONAL. SEE REVERSEl()57 -64-7 58 7
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(ST ATE) J... (COUNTY)
C. CHECK ONE Q CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESs31-D Scarborough Lane
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl062_72_6033
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY 8. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY-a TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 31-D Scarborough Lane ZIP 12590
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
3 A AGE 37 38. DATE OF BIRTH 03 /12 /1972
MONTH DAY YEAR
MONTH
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE34 38. DATE OF BIRTH 11 /1'7
12t)~U
ZIP
DYES '6 NO
~974
DAY
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Lineman
8. TYPE OF INDUSTRY OR BUSINESS Utility
5. PLACE OF BIRTH Poughkeepsie, NY
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME Temple Douglas Lewis
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jo Ann Pennix
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 Hairdresser
B. TYPE OF INDUSTRY OR BUSINESS Cosmetologist
15. PLACE OF BIRTH Carmel, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Ronald Paul VanCoughnett
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Karen DiCarmine
B. COUNTRY OF BIRTHU S A
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) 0 DIVORCE
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
C. DATE LASTMARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCEO 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
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
o 1ST
o 2ND
o 3RD
o 4TH
belief that the information I provided is t
o
o
o
21. SIGNATURE OF GROO
US URREN
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 911 to perform marriage ceremonies within 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
{ } NAME (PRINT) Jo . Ma
TIME MONTH YEAR
SEAL SIGNATURE ~ TE
MAILING ADDRES 08:35AM 04
'-.r-' 20 Midd PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
by New York Domestic
MONTH
YEAR
06
06 2009
08
2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN.;;j;1t.1, n tfI,\5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF ~LLAGEW
SPECIFY ".,~ ,;c:.6\i1.
SIGNATURE~ .
DOH-98 (03/2006)