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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Neil ,11;t9mas MaQ~~ SURNAME
COUNTY Dutchess
CITYITOWN Wappinger
~~~:kcr: 1368
~5~1:~~R 11 6
1 . A FULL NAME
FIRST
Q.
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 114-62-4079
2. RESIDENCE A. NYSTATE) B. ~)ess
C. CHECK ONE 0 CITY $J TOWN 0 VILLAGE
AND .
SPECIFY Wappinger
D STREET ADDRESS 50 Scott Dri\lP ZIP 1 ?!i~O
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESIl:! NO
M~4 /?r.Q / ~~g
3. A AGE20
4. EMPLOYMENT
3B. DATE OF BIRTH
A USUAL OCCUPATION NYS Health Dept
B. TYPE OF INDUSTRY OR BUSINESS \Nater Treatment
5. PLACE OF BIRTH 'Yc~frr,I~co~~Y IF NOT USA)
6. FATHER
A NAME Harold john Madison
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A MAIDEN NAME Barbara Angela Yotz
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
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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) ICITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
"'All: ~ILI: NUMtlEH
(THIS SPACE FOR STA TE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
T arJtbD~arie R aCt~RENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~I'b~i~~~~EA~~o~~Madison
D. SOCIAL SECURITY NUMBER 114-RR-O 1 R 1
12. RESIDENCE A NY(STATE) B.~~SS
C. CHECK ONE 0 CITY o/lJ TOWN 0 VILLAGE
AND \N .
SPECIFY ::!rrmopr
o STREET ADDRESs.l)O Scott Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A AGE25 3B. DATE OF BIRTH ~dNTH ~~AY ~~~~
14. EMPLOYMENT
A. USUAL OCCUPATION Speci~1 Frlllc~tinn T e::!r.hAr
B. TYPE OF INDUSTRY OR BUSINESS FdLJcation
15. PLACE OF BIRTHl.nrtl::mrlt N~
(CITY, STATE / C6UNTFlY IF NOT USA)
16. FATHER
A. NAME Thomas Ger~ld R~cek
B. COUNTRY OF BIRTf-l J S A
17. MOTHER
A. MAIDEN NAME .hlliA Ann O'Connell
B. COUNTRY OF BIRTHl J S 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
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, 'F NOT USA) SELF SPOUSE
o
o
o
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the marn~ge S <'
21. SIGNATURE OF GROOM. 22. SIGNATURE OF BRIDE.
USE C
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New 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.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
,-.I'-..
{ SEAL }
'-v-I
NAME (PRINT)
DATE
08/26/2008
by New Yorl< Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
12:06PM 08
25 2008
27
2008
10
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
~RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
WN
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
28. PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B. couN-J/l!5fc..f.,1E5jt;,tP
C. LOCATION OF CEREMONY
/~ LJ .. /.J (CHECK ONE AND SPECIFY)
{~U:Jr p/.r1lpj.,J- -
o CITY OF JIJ TOWN OF 0 VILLAGE OF
SPECIFY {.ot71J1 Aldl
SIGNATURE~