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COUNTY Dutchess
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NUMBER 127
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jal'ti1~ Rcnald ~~NT SURNAME
FIRST
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Ja~b!!~lin8 Hin~RRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 042 7 B 0705
2. RESIDENCE A. N'(STATE) B. ~p3G
C. ~~6CK ONE 0 CITY.!J TOWN 0 VILLAGE
SPECIFY FiGhkil1
D STREET ADDRESS 1616 Lyndhurst W.y ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES.,l] NO
3 A AGE 37 3B. DATE OF BIRTH MJ;l~ / a7 / ~W1
4. EMPLOYMENT
A USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Retail
5. PLACE OF BIRTH I M"l+".".h I J.r\I f"+
'fCI1'I".'ll1'Al'!:'n::olJNTm'lF NOT USA)
6. FATHER
A NAME Ronald 1\lIcn I\pril
B. COUNTRY OF BIRTH Canada
7. MOTHER
A MAIDEN NAME Ann Smith
B. COUNTRY OF BIRTH Scotland
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
C. SURNAME AFTER MARRIAGE Idl'n..lg 1'\ nril
(OPTIONAL - SEE REVERSE) \;I , 'I'"
D. SOCIAL SECURITY NUMBER 045- 78-4396
12. RESIDENCE A NY'STATE) BD~)ss
C. CHECK ONE 0 CITY,JlJ TOWN 0 VILLAGE
~~~cIFYFishkill
o STREET ADDREss161 h I ynrlhllr~t W~y zIP1 ?590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESolJ NO
~bNTH ~~AY (~lJ
13. A. AGE35
14. EMPLOYMENT
A. USUAL OCCUPATloNB.kery Manager
B. TYPE OF INDUSTRY OR BUSINESS Grnr.ery
15. PLACE OF BIRTH\~~~~~~~I/I[~NT~tIF NOT USA)
16. FATHER
3B. DATE OF BIRTH
,A. NAMEJack Dougl.!; Hinds
B. COUNTRY OF BIRTH I ~ A
17. MOTHER
A. MAIDEN NAME Mary 'arE" Antnnp.1Ii
B. COUNTRY OF BIRTH I S A
18. NUMBER OF THIS MARRIAGE 2
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH / DAY / YEAR C. DATE LAST MARRIAGE ENDED? MONTP1 / g,,~ (. ~2.~R
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
"
1D. 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
o 0 1 ST 0 1/08/1998 \AI~tp.rhllry, r.t 0
o 0 2ND 0
o 0 3RD 0
o 4TH
and belief that the information I provided is
o
o
o
1
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the mama
23. SUBSCRIBED AND SWORN IAF MED BEFO
SIGNATURE OF TOWN 0 LERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 tD 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
DATE
by New York Domestic
w
en
z ~
w
~ { SEAL }
'-v-'
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DATE
AM
02:41 PM 09
05
2008
11
03 2008
STATE
27. TYPE OF CEREMONY
o)\i RELIGIOUS
9 0 OTHER, SPECIFY
1 D CIVIL
I
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
/J 30 AM 10 If' JO(?l{
~~~t~~~~~T !/(!tv/&,q L. '6ec~.e'~
SIGNATURE~ "j!# ~ ~~"'-
MAILING ADDRE ~ r;;;> L ~
1/ v?4- //f~/t(&4
STREET CITYfTOWN
30. WITNESS TO CEREMONY
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~flV4-(v'\....
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF )( VILLAGE OF
SPECIFY C-o\c~ 5rr1 n 8
TITLE ~re,ee~
/t,l'/,f"O?
/~j/~
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
SIGNATURE~