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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Rodgers Limer, Jr,
MIDDLE CURRENT SURNAME
DATE 11/21/2008
F lis NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~CRT 1368
~~~I:l~R 175
1. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE),.,
D. SOCIAL SECURITY NUMBER ..:::45-49-7898
2. RESIDENCE A. NY B Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY..Q TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 1202 Hudson Harbour DrivezlP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A AGE ~4 3B. DATE OF BIRTH 1 0 / 17 /1974
MONTH DAY YEAR
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is tru
as to my right to enter into the marr ge &tate. ~
21. SIGNATURE OF GROOM~ u-- -c: ./ ,
USE C NAME
23. SUBSCRIBED AND SWORN TOIAFFIRMED BEFORE ME : 1
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y State of the bride and groom named above by a y 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
4. EMPLOYMENT
A USUAL OCCUPATION Store Manager
B. TYPE OF INDUSTRY OR BUSINESS Auto Parts
5. PLACE OF BIRTH Henderson. NC
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A NAME Michael Rodgers Limer, Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Mary Frances Roberson
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
n 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH OA Y 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
~
{ SEAL}
'-v-I
NAME (PRINT)
n
ITY WN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
Joo~
29. OFFICIANT
NAME (PRINT)
TITLE
DATE
l
STRE
30. WITNESS TO CEREMONY
NAME (PRIND 1~',"\r1. Q u.
I
SIGNATURE~
DOH -98 (03/2006)
~qo
STATE
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Jamie Lee Pulst
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
8. 81RTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Limer
(OPTIONAL. SEE REVERSEb94_80_517 4
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 1202 Hudson Harbour Drive ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
13. A. AGE26 3B. DATE OF BIRTH 10 Al4 ;1'982
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Housekeeping
B. TYPE OF INDUSTRY OR BUSINESS Cleaning
15. PLACE OF BIRTH Beacon I Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Christian I. Pulst, Jr.
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Christine May Sullivan
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
o
o
o
22. SIGNATURE OF BRIDE ~
DATE 11/21/2008
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
01 :48PM
2008
01
20 2009
11
22
1 ij;?CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY f.)v I Cl~ e 7~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF u;r"fOWN OF 0 VILLAGE OF
1l14t<R/1tGf Or;r:IGtR....
I z{ 1 {2c'Df
SPECIFY
u)A;P (J IIJ(' E I?.
NAME (PRINT)
SIGNATURE~