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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
DeVerillk~uii~ Tr~~~~~URNAME
COUNTY Dutchess
CITYfTOWN \^'appinger
DISTRICT . .
~~~I~~~R1368
NUMBER 120
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
..
N
1. A. FULL NAME FIRST 8tcPitma Miohael Pu~SURNAME
B. BIRTH NAME, IF DIFFERENT Douglas
c. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 066 62 7810
2. RESIDENCE A. N"(sTATE) B. QgiOOpoG
C. CHECK ONE 0 CITY JJ TOWN 0 VILLAGE
AND
SPECIFY IJVappinger
D. STREET ADDRESS 15 Brothers Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES.,l] NO
MJ.1~ / aA~ / J~ 1
11. A FULL NAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
FIRST
C. SYS~~roEN~~~~rEA~~C~~s~Y3tt
D. SOCIAL SECURITY NUMBER 065-48-8306
12. RESIDENCE ANY(STATE) B.o~~SS
C. CHECK ONE 0 CITY.Jl] TOWN 0 VILLAGE
~~~CIFY'^'appinger
D. STREETADDREss1fi RrnthAr!=: Rn::trJ ZIP1?590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESol] NO
Q~NTH /-f ~AY ,( ~ae
13. A. AGE52
14. EMPLOYMENIT
A. USUAL OCCUPATIONR~ceptioniSit
B. TYPE OF INDUSTRY OR BUSINESS MArJir.::tI
15. PLACE OF BIRTH-Q,9pm~~~~~y It"N't,. USA)
16. FATHER
,A. NAMEVValter )ohn Treadway
B. COUNTRY OF BIRTH. J S A
17. MOTHER
A. MAIDEN NAME Rite Frances 'Alright
B. COUNlTRY OF BIRn" I S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
3. A. AGE47
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Courier
B. TYPE OF INDUSTRY OR BUSINESS Transportation
5. PLACE OF BIRTH ~~~ III/j:
, '/ ~o RY IF NOT USA)
6. FATHER
A. NAME Hugh Saunders Pyatt
B. COUNTRY OF BIRTH U S fl.
7. MOTHER
A. MAIDEN NAME Marcia V. Douglas
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
(3) 0 DIVORCE
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
~
3B. DATE OF BIRTH
o
DEATH
o
MONTH DAY
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ (
MONTH DAY YEAR
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
YEAR
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa~ th t t
as to my right to enter into the ma
21. SIGNATURE OF GROOM ~
1ST
2ND
3RD
22. SIGNATURE OF BRIOE
{L/}~JLo
US
23. SUBSCRIBED AND SWORN TO/AFFI EO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
W Relations Law ~11to perlorm marriagB ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
en 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony,
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W } NAME(PRINT) J~CrM~~~
~ {SEAL SIGNATURE~C:U ~A.6-.. ~ DATE 08/28'2008
MAILING ADDRESS AM
'-v-I STRfJ) Middlel3Llsh Rd, \^/;lp~J~ F~II!=:'sh'1 1?fiqQ,P 02:57PM 08
~~~R~~RT~J IO~O~~~N~EE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 0 RELIGIOUS 1)5 CIVIL
~tI~E ~~glc~~i~E TIME AND,.AM 0 f? 9 0 OTHER, SPECIFY
TIME
STREET I CITYfT WN
30. WITNESS TO CEREMONY tff;;:. ~
NAME (PRINT) 'b_t.>:_N. ~
SIGNATURE~ ( 1. r..l __'i (' L
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
ClnMATIIOE:.....
o 0
o 0
o 0
o 0
impediment exists
by New York Domestic
MONTH
YEAR
MONTH
YEAR
29
2008
10
27 2008
28. PLACE WHERE MARRIAGE OCCURR~
A. STATE NEW YORK B. COUNTY )1IIJL.bictJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY {;;.../l~IJ.,f':j pdt,; /J-! C,