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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~~T 1368
~~~I~;~R 1 9
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Allen Imm, Jr.
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jaclyn Emily Smith
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
ll.
N
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Smith-Imm
(OPTIONAL. SEE REVERSEl082_88_6740
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. NY B. Dutchess
(STATE) J. (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREETADDRESS 48 Scott Ur.
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEJ084_62_6145
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY '!"J TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 12 Malstorme Rd, ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
08 /03 /1978
DAY YEAR
1 LOtlU
ZIP
DYES [] NO
/1'980
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE 29 3B. DATE OF BIRTH 02 fl2
MONTH DAY
3. A AGE 30
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A USUAL OCCUPATION Surveyor
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Poughkeepsie, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME Robert Allen Imm Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Phyllis Suzanne Stratton
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 Student Teacher
B. TYPE OF INDUSTRY OR BUSIN~r Education
15. PLACE OF BIRTH Yonkers, Y
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME John EUBene Smith
'B. COUNTRY OF BIRTH S A
17. MOTHER
A MAIDEN NAME Kathleen Ann Blaikie
B. COUNTRY OF BIRTH U S A
1
18. NUMBER OF THIS MARRIAGE
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,- YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
,.
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 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
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 declare that no egal, impe iment exists
as to my right to enter into the marn e state. ~
21. SIGNATURE OF GROOM~ a... . 22. SIGNATURE OF BRIDE~ '
USE C RE T NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 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.
,-I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Joh
{ 04/06/200 TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
"'-- -..J MAIl.l1W (I\lDI)~E~Se. AM 7 09 0 2009
-v- LU IVI aal in ersFalls, NY 12590 03:45PM 04 0 20 06 5
STREET CITYfTOWN STATE ZIP
~~:~~Ri~~~ 10~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY 1 ~ '/CIVIL
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS I..IrCI'
DATE AND AT THE TIME AND /. <.00 AM "'u L1 00 ') a
PLACE INDICATED. \C I , '\ -\ cx()O { 9 0 OTHER, SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
29. OFFICIANT -!"':" (' A, C-" I?"
NAME (PRINT) .JOHf\ . (Y\ ~1~:"C>i\
SIGNATURE ~ en e 11/.1I~ J
MAILING ADDRESSQ llJ
dO tv'l,l\t) l(iQ,U.> VI (<,':1' W/t()(J1 ~M?Q)
STREET ' CITYfTOWN
30. WITNESS TO CljMONY .
NAME (PRINT) c.;'l I e.
SIGNATURE~
DOH.98 (03/2006)
A. STATE NEW YORK B. COUNTY tIJT(' \-I f' ~ 1\
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
TITLE IYI A1<R, fllif'i. 0(..[\ ~
DATE~ d-C'Dq
Ny'
STATE
SPECIFY ijJA(JP ff\:J (;(=-R...
h4-11S
"S ."" ,~
~
NAME (PRINT)
SIGNATURE~
