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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~~ 1368
~5~~~~R 159
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
.-l
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
Rnn::lld Fn:'!dp.rick L::Ifko
MIDDLE CURRENT SURNAME
FROM THE BRIDE
Barbara Ann Jensen
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENTMackey
C. SURNAME AFTER MARRIAGE Jensen
(OPTIONAL - SEE REVERSE)1 01 32 3207
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEANY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY apPlnqer
o STREET ADDRES~45 Myers Corners Road
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)055 34 6396
D. SOCIAL SECURITY NUMBER ___ - __ - ____
2. RESIDENCE A. NY B. [)lJtchp.ss
(STATE) (COUNTY)
C. CHECK ONE 0 CITYolJ TOWN 0 VILLAGE
AND W .
SPECIFY appmger
o STREET ADDRESS 79 Helen Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
3. A. AGE 66 3B DATE OF BIRTH n~ / nfi / 1 ~42
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE67 3B. DATE OF BIRTH 12 ,.16
MONTH DAY
ZIP 12590
o YES~ NO
.%940
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION RA::II Fstate Agent
B. TYPE OF INDUSTRY OR BUSINESS Real Estate
5. PLACE OF BIRTH ~\~~Q~E / ~~NTRY IF NOT USA)
6. FATHER
A. NAME FrArlArick .Inhn I afko
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Barbara Brewster Howroyd
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Housewife
B. TYPE OF INDUSTRY OR BUSINESS Housewife
15. PLACE OF BIRTHNewburqh, Nv
(CITY. ST ATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Walter Andrew Mackey
. B. COUNTRY OF BIRTJ.l S A
17. MOTHER
A. MAIDEN NAME Bessie Paltridqe
B. COUNTRY OF BIRTJ-l S A
18. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
1
(3) 0 ANNULMENT (2) ~ DEAtH
/ 2003' .
- YEAR
DEATH
1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 1'!1 DEATH
C. DATE LAST MARRIAGE ENDED? 07 / 16 / 2003
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) AliVE? 0 YES I'!l'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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED? 01 / 16
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES tj 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 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
dgn yrd belief that the information I provided is true and that I declare that no legal impediment exists
U 22. SIGNATURE OF BRIDE ~ ~-ov.1 o..J\ Q., 0. ~ NI ~/)\.
USE CURRENT N~
DATE 10/14/2008
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and SlIY, at t e be
as to my right to enter into th~a~r1age ate.
21. SIGNATURE OF GROOM ~ ,r "
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y k 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.
r-"-. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo C. Master.son
TIME MONTH YEAR
SEAL SIGNATURE ~" DATE 1 0/14/2008
MAILING ADDRESS 11 : 57 AM 1 0
'-v-I STRtR Middle ush Rd, Wap~~fT~~Js Falls's~Tr 1259qlP PM
~~~R,;;~~RT~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 g RELIGIOUS 1 0 CIVIL
~~6E ~~gIC'j.,~~~E TIME AND AM 9 0 OTHER. SPECIFY
by New York Domestic
MONTH
YEAR
12
13 2008
15
2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY D",TcH~.s5
NAME (PRINT)
SIGNATURE~
DOH.98 (03/2006)
NAME (PRINT)
SIGNATURE~