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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~CRT136R
~~~~J~R 160
~ I A II:. UI"" NI:. VV T UHI\
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
"Ist~oo~g::!rr. ~hl'rg~i~ SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Anandadevi Wint
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SDCIALSECURITYNUMBER 072-74-2740
2. RESIDENCE A NY B. nlltr.hess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
AND W .
SPECIFY ::!rrlnger
D STREET ADDRESS 207 Old Castle Point Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
3. A. AGE29 3B. DATE OF BIRTH n1 / ?? /1979
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Shumway
(OPTIONAL - SEE REVERSEb
D. SDCIALSECURITYNUMBER 73-70-3070
12. RESIDENCE ANY BPutnam
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFYPutnam Vallev
D. STREET ADDRES~53 Church Road
ZIP 10579
DYES"6 NO
;(982
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE.'25 3B. DATE OF BIRTH 11 ~2
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Cch1e\lisinn News
B. TYPE OF INDUSTRY OR BUSINESS Television
5. PLACE OF BIRTH POlJahkeepsie Nv
(CITY. !:fATE / COUNTRY IF NOT 'GSA)
6. FATHER
A. NAME Stephen .Inhn ~hllmw::!y
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Diane V Mauritz
B. COUNTRY OF BIRTH L J S A
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 TO Sanknorth
B. TYPE OF INDUSTRY OR BUSINESS Sa n ki nQ
15. PLACE OF BIRTHManhattan, Nv
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMElan Keith Wint
'B. COUNTRY OF BIRTJ-l S A
17. MOTHER
A. MAIDEN NAME Deborah Elizabeth Sawyer
B. COUNTRY OF BIRTJ-l 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
(2) 0 DEATH
DEATH
o
B. HOW Q!Q. LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
,.
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
1ST
2ND
3RD
4TH
I duly swear/affirm. depose and s
as to my right to enter into the
21. SIGNATURE OF GROOM ~ .
o
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
t no legal impediment exists
22. SIGNATURE OF BRIDE ~
w
en
z
w
(.)
:;
US
23. SUBSCRIBED AND SWORN 1: IAFFIRMED BEFORE M
SIGNATURE OF TOWN OR ITY CLERK ~
This license authorizes the marriage in New Y State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies wit in 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
10.'15/2008
DATE
by New York Domestic
~
{ SEAL }
'-..t-'
NAME (PRINT)
YEAR
TIME
MONTH
YEAR
MONTH
DATE 10/15/2008
ers Falls NY 12590
WN STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS 1 ~
9 0 OTHER, SPECIFY
08:53AM
PM
10
16
2008
12
14 2008
28. PLACE WHERE MARRIAGE OCC~
A. STATE NEW YORK B. COUN~Tt,~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY ~J.~ ~ i~LL
. (259-0
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
5 Ir. 1/\0 V\'\ voJ (N ...../
I
NAME (PRINT)
SIGNATURE~