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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Juli4io&irant RaY~~suRNAME
COUNTY Dutchess
CITYrrOWN \j\/appinger
~~~:~c: 1368
~~~~J~R 148
1. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cha~a.~f1 Lynl1 [)~0l~NTSURNAME
.J
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 050-72-2946
2. RESIDENCE A. N'(STATE) B. ~~)8SS
C. CHECK ONE 0 CITY 0 TOWNJ[] VILLAGE
~~~CIFY VV.ppingeri Falls
o STREET ADDRESS 2650 Fast M~in ~trp.p.t ZIP 1 ?!i~O
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? olZi YES 0 NO
M~4 / '6.7 / ~1
3. A. AGE 27
4. EMPLOYMENT
3B. DATE OF BIRTH
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~*~M~~~rEA~~lb~~~aymond
D. SOCIAL SECURITY NUMBER O~!i- 7 f)-~f)4!i
12. RESIDENCE ANY(STATE) BD\~oCG~~SS
C. CHECK ONE 0 CITY 0 TOWN~ VILLAGE
~~~CIFYW~rringp.r!; F~II!;
D. STREET ADDRES1l2650 East Main Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ..0 YES 0 NO
nR ~ 6 ,.,(Q7Q
l.41mTH OA Y YEAR
13. A. AGE29
14. EMPLOYMENT
A. USUAL OCCUPATION Sllrp.r\li~nr
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
15. PLACE OF BIRTH Nnrth Tarrvtnwn Nv
(CITY. STATE / COUNTRY IF NOT US;()
16. FATHER
A. NAMEBplce l::lmes nrino, ~r
'B. COUNTRY OF BIRTHl J S A
3B. DATE OF BIRTH
17. MOTHER
A. MAIDEN NAME Christine f)rahns
B. COUNTRY OF BIRTHLJ ~ 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
A. USUAL OCCUPATION Salesman
B. TYPE OF INDUSTRY OR BUSINESS A lito
5 PLACE OF BIRTH lTc~n~/~~T~t~'N~~SA)
6. FATHER
A. NAME David 'lVayne Raymond
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Lorey SLle Adams
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
o
o
C. DATE LAST MARRIAGE ENDED?
MONTH OAY
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 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3AD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare 1hat no legal impedirT\Elnt exists
as to my right to en1er into the mVIa;le state. /J A ' t./ /i
21. SIGNATURE OF GROOM ~ w~ 22. SIGNATURE OF BRIDE..c g ~ K.... t7. ,(y~
SE CRUSE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/ FFIRMED BEFORE ME 0 08
SIGNATURE OF TOWN OR CITY CLERK ~ DATE _ -
This license authorizes the marriage in New Yo Slate of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to periorm 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)
DATE
TIME
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 DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
~
{ SEAL }
'-..,-I
YEAR
MONTH
YEAR
MONTH
O~/?R/?OOR
ZIP
AM
12:54PM 09
27
2008
11
25 2008
ITY WN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
II
STATE
27. TY~ OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCC~E~
A. STATE NEW YORK B. coJl-#"-~
C. LOCATION OF CEREMONY
(CHECK ONE A~PECIFY)
o CITY OF~To~m, OF 11 8 VILLAGE OF
SPECIFY ~) Y
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
I
SIGNATURE~
DOH-98 (03/2006)