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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Cra~lJMich::lel CQ~SURNAME
o
6. HOW DID LAST MARRIAGE END? (3) i1'I DIVORCE 13) 0 ANNULMENT (2) 0 DEATH 6. HOW DID LAST MARRIAGE END? (3) fi!'l DIVORCE 131 0 ANNULMENT 12) 0 DEATH
/ / . / /
C. DATE LAST MARRIAGE ENDED? MONTH 06 D~3 ~Q08 C. DATE LAST MARRIAGE ENDED? MONT~1 l? _ ~9.Q7
D. ARE ANY FORMER SPOUSE(S) ALIVE? IitYES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
06/23/2008 Macon, Ga 0 ~ 1ST 01/1 ?/?007 PArry. ~::l r!!' 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
my knowledge and belief that the information 1 provided is tru legal impediment exists
COUNTY Dutchess
CITYiTOWN \Mappinger
DISTRICT . .
NUMBER 1 :368
REGISTER
NUMBER 128
1 . A. FULL NAME
FIRST
a.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 264 65 4 5 g4
2. RESIDENCE A. NV B. no .+..-hess
~STATE) ""loo"!Jliffi/j
C. ~~6CK ONE 0 CITY JJ TOWN 0 VILLAGE
SPECIFY Poughkeepsie
D STREET ADDRESS 567 Sheafe Road; Lot #4 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES..l] NO
M~~ / dA~ / ~i?8
3. A. AGE40
4. EMPLOYMENT
36. DATE OF BIRTH
A. USUAL OCCUPATION Restaurant Manager
B. TYPE OF INDUSTRY OR BUSINESS Hospitality
5. PLACE OF BIRTH <;EffNmp~h QQ
, / T I NOT USA)
6. FATHER
A. NAME OSC::lr .Jerome Cogan
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Janice Sharon Rosen
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1
o
o
1ST
2ND
3RD
4TH
I duly swear/affirm. depose
as to my right to enter into
21. SIGNATURE OF GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
LisioMail 4.tta\p/~~RRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. SYS~~~N~~~~~t~~c~~~ogan
D. SOCIAL SECURITY NUMBER ?i:\R-A3-4q7q
12. RESIDENCE AG~ B.Hnl.c>tnn
. iSTATE) Tc"Oi:'lrn'I'l
C. CHECK ONE >CJ CITY 0 TOWN 0 VILLAGE
~~~CIFy'^'arner Robins
D STREET ADDREss11!1 Olri Mi~~inn Way ZIP31 088
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VilLAGE? ..tJ YES 0 NO
13. A. AGE27 3B. DATE OF BIRTH ~NTH /-f .'ty ~ ~g~
14. EMPLOYMENT
A. USUAL OCCUPATIONHomemaKer
B. TYPE OF INDUSTRY OR BUSINESS HnmAm::lkAr
15. PLACE OF BIRTH ~Cf~~AT~ fOUNTRY IF NOT USA)
16. FATHER
,A. NAMEJohn Marion Attaway
B. COUNTRY OF BIRTH) S A
17. MOTHER
A. MAIDEN NAME I inrl::l G::lyIA nl In::lO::ln
B. COUNTRY OF BIRTt-i I S A
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1
DEATH
o
This license authorizes the marriage in New York tate 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
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{ SEAL }
'-y-I
NAME (PRINT)
TIME
MONTH
YEAR
MONTH YEAR
AM
01 :33PM 09
06
2008
11 04 2008
l~L
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 'D. .ki. ("> )
C. LOCATION OF CEREMONY
(CHECK ONE AND )l*'CIFY)
o CITY OF ~OW~ OF 0 VILLAGE OF
SPECIFY ? C u~ l rc .QY~s..\,O
""
TITLE .,.. 15" ~+, ~ (\2;:. + )
DATE q \'1ld-60<(
\i (V\ '\~~.3>~
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINTl ~.'
SIGNATURE~