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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nemiah Wayne VanGuilder
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOW.N Wappinger
DISTRICT 1 368 .
NUMBER
REGISTER 8
NUMBER
1 . A. FULL NAME
FIRST
0-
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)115_70_0549
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 27 E Surrey Lane
12b90
ZIP
YES '6 NO
/ 1977
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 31 3B. DATE OF BIRTH 06 / 02
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Director Of Quality Improvement
B. TYPE OF INDUSTRY OR BUSINESS Medical
5. PLACE OF BIRTH Glens Falls, Ny
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME GeorQe Wayne VanQuilder
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patricia Marion McCollum
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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 OECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dawn Marie Perez
-.J
11. A. FUll NAME
CURRENT SURNAME
FIRST
MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)072-64-5172
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK Otl~ . 0 CITY [J TOWN 0 VILLAGE
~~~CIFY vvapplnger
'2.1 I::. ~urrey Lane
D. STREET ADDRESS
13. A. AGE 29
09
12590
ZIP
YES ~ NO
;t979
YEAR
3B. DATE OF BIRTH
MONTH
DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Director Of Operations
B. TYPE OF INDU&,RY O~~USIN'NS Medlc.al
15. PLACE OF BIRTH roo yn, y
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Maurice Amaral
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Bernice Perez
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEbTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (,
MONTH DAY YEAR
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 0 1ST 0
o 0 2ND 0
o 0 3RD 0
o 0 4TH 0
e and belief that the information I provided is true and that I declare that no legal imp
w
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~
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-.-' MAI2cr ~?d
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and . say, that to the b~st O.fZk. Ie
as to my right to enter into the marnage state."
21. SIGNATURE O~ GROOM. ." ~/ -" ~ -t. "" v/
US CU ENT
23. SUBSCRIBED AND SWORN O/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 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
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH -9B (03/2006)
/)11,
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
03:25PM
03
05
01 2009
2009
03
28. PLACE WHERE MARRIAGE OCCUR~\~
A. STATE NEW YORK B. COUN"f'IIll.VJ-!e i~'5>
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY O~~OWN OF 0 VILLAGE OF
SPECIFY (,l ')O~ i~~ r
v / . /
NAME (PRINT)
SIGNATURE~