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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1 368
~5~li~~R 11 0
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sabrina Lea Stewart
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
Rri::l~ID~'illi::lm RrPc~m~~~SURNAME
FIRST
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rn:mnan
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 058-62-2524
12. RESIDENCE ANY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D STREET ADDREss3 Fishkill Glen Drive; Unit F
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 080-72-2649
2. RESIDENCE A. NY B. nlltr.hp!=:~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY.zJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D STREET ADDRESS 3 Fishkill Glen Drive: Unit F ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 31 3B. DATE OF BIRTH nc; / 14
MO):i-i'fi DAY
4. EMPLOYMENT
A, USUAL OCCUPATION Ilnion Stpamfittpr
B. TYPE OF INDUSTRY OR BUSINESS Tradesman
5. PLACE OF BIRTH Town Of Cortlandt
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Willi::lm .Io!=:prh Rrpnnan
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Barbara Florence Sundstrom
B. COUNTRY OF BIRTH USA
6. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
o
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
ZIP 12524
DYES tJ NO
;(977
YEAR
12524
YES otJ NO
/1 q77
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ~n 3B. DATE OF BIRTH 08 ~ 1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Bookkeeper
B. TYPE OF INDUSTRY OR BUSINESS Accounting
15. PLACE OF BIRTH Beacon
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William Henry Stewart
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Penny Jean Hopoer
B. COUNTRY OF BIRTHU 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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
C. DATE LAST MARRIAGE ENDED?
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
~
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
II:
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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 and that t-declare th
as to my right to enter into the marnage state.
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ t
o 0
o 0
o 0
o 0
I impediment exists
w
en
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()
;:j
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork State of the bride and groom named above by any person authorized
Relations Law 911 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
C. Ma terson
C
MONTH
YEAR
DATE
08/20/2008
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
TIME
MONTH
DATE 08/20/2008
ush Rd. Wapoinaers Falls, NY 12590
CiTYii'l'iWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 ~ RELIGIOUS
SIGNATURE ~
MAILING ADDRES
20 Middl
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED. 4: 00 PM
AM
05:39PM 08
21
2008
10
19 2008
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Dutchess
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
XXCITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY Poughkeepsie
9-6-08
9 0 OTHER, SPECIFY
29. OFFICIANT Daniel B. Ward
NAME (PRINT)
SIGNATURE~~
'MoILING A,DDflES, .
~t. John s Lutheran 55 Wllbur Blvd.
Pastor
TITLE
9-6-08
DATE
Poughkeepsie, NY 12603
STATE
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
SIGNATURE~