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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368
~~~I;~~R 17
:s I A II: UI- NI:W YUHf\.
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ravmond Gerard Wall
MIDDLE CURRENT SURNAME
FIRST
(TH/S SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Donna Jean Jones
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FUll NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Jones-Wall
(OPTIONAL - SEE REVERSE) 111-54-5375
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) w'i (COUNTY)
C. CHECK ONE 0 CITY J:J TOWN 0 VILLAGE
D :~:~~7A:~E~s~hok~:~~n Harbour Dnve
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY
(STATE)
C CHECK ONE 0 CITY >rJ TOWN 0
~~~CIFY PouQhkeepsie
D STREET ADDRESS 10 Hudson Harbour Drive ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES tJ NO
01 /19 /1975
MONTH DAY YEAR
B. Dutchess
(COUNTY)
VILLAGE
ZIP 12601
DYES~NO
/f974
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 34 3B. DATE OF BIRTH 07 /1 0
MONTH DAY
3. A. AGE 34
3B. DATE OF BIRTH
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Carpenter
B. TYPE OF INDUSTRY OR BUSINESS Carpentry
5. PLACE OF BIRTH Ennis, Clare, Ireland
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION School Social Worker
B. TYPE OF INDUSTRY OR BUSINESS Social Work
15. PLACE OF BIRTH Poughkeepsie, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME GeorQe David Jones
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Julie Anne Behan
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
....
>
<
C
wU:
"'u..
;j<
6. FATHER
A. NAME Vincent Wall
B. COUNTRY OF BIRTH Ireland
7. MOTHER
A. MAIDEN NAME Mary Falvev
B. COUNTRY OF BIRTH Ireland
8. NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HDW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END?
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
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 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 swe~r/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is trrJu and that I declare t:]hat 0 leJgal'mpediment exists
as to my Tight to enter Into the arnage state. rJ ,n./1 ' ^
21. SIGNATURE OF GROOM~ Wtt 2. NATURE OF BRIDE~ I)U M '~.A/ L! #-
USE CURRE A USE CURRENT NAME
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 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.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Joh
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ E 04/03/200
MAILING ADDRESS NY 12590 AM 04 04 2009 06 02 2009
'-..-I 20 Middle 02:00PM
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE
04/03/2009
YEAR
~IL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Abkio6
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF'~WN OF 0 VILLAGE OF
SPECIFY it) ~!/1'J1e.r
NAME (PRINT)
SIGNATURE~
DOH-9B (0312006)
SIGNATURE~