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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
/\rFillfiMd ThomaG8~TSURNAME
COUNTY Dutchess
gl~~c?TWN VVappinger
~~~I~~~R1368
NUMBER 1 01
1 . A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 09'1 36 9037
2 RESIDENCE A. N'X,TATE) B. Q!d~~OGC
C. CHECK ONE 0 CITY 0 TOWN Jtl VILLAGE
AND
SPECIFY W3ppingers Falls
D STREET ADDRESS 76 South Meiier A\le ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Ql YES 0 NO
3. A. AGE 62 3B. DATE OF BIRTH MOW / J.p / :e~5
4. EMPLOYMENT
A USUAL OCCUPATION Laboratory Technologist
B. TYPE OF INDUSTRY OR BUSINESS Medical
5. PLACE OF BIRTH Q~ I\J..Y'
'{t:1'rV:""sYII'f~ , tOll'NtRY IF NOT USA)
6. FATHER
A NAME Riohard Carl Ruf
B. COUNTRY OF BIRTH Ij S A
7. MOTHER
A MAIDEN NAME Doris Betty Talbot
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHIGH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
1D. 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
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Do~~~n~ BroW~ENTSURNAME
~
11. A FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Benedict
C sY~~~~rA~~~~t~~ms~uf
D. SOCIAL SECURITY NUMBER 068-60-1395
12. RESIDENCEA.N"'STATE) B.D~t3;;~aa
C CHECK ONE 0 CITY 0 TOWN 012! VILLAGE
~~~cIFY'^'appingers Falls
D. STREETADDREss7F\ ~nJlth Mp.~ip.r Avp. ZIP1?S90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? <tJ YES 0 NO
13. A. AGE 46 3B. DATE OF BIRTH Q~TH ~~AY .-1 ~8~
14. EMPLOYMENT
A. USUAL OCCUPATION Housewife
B. TYPE OF INDUSTRY OR BUSINESS Hnll~p.)Nifp.
15 PLACE OF BIRTH Peekskill NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
,A. NAME George Edward Benedict, Sr
B. COUNTRY OF BIRTH I I ~ A
17, MOTHER
A. MAIDEN NAME EliZ';1bett'1 SliP. Ri~r.hnff
B. COUNTRY OF BIRTH I J S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A.NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0 1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (21 r!f DEATH
C, DATE LAST MARRIAGE ENDED? 06 / 09 / 1999
MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ~ 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
o 0 1ST 0 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
and belief hat the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE~ ~~~E ""'_L
DATE 08/05/?008
U
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies ithin 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
21. SIGNATURE OF GROOM.
W
en
z
W
o
::i
~
{ SEAL}
'-.,-I
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
AM
01 :50PM
08
06
2008
10
04 2008
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TATE
27. TYPE OF CEREMONY
o ~LIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY l)L"/c;;t'~r
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ff'VILLAGE OF
SPECIFY tJA'Pp/vJt.d .r;,.11~
ITY
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
~!IJO A 0 ( !i,P Zoo
./fe-r" (e {' he" Ie.
[At-;L (!j.-t &l d~, -+
f7k u- t.A.
CITYrTOWN
4
29. OFFICIANT
NAME (PRINT)
TITLE
DATE
NAME (PRINT)
tvl
nr\u no In'] Il")nn~\
,r&. c I-c V-
'9';!1c !IJ V
~ I
/I.) ( / ;;J9 I)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~