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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Do~,^.aron N~SURNAME
COUNTY Dutchess
CITYrTOWN '^'appinger
DISTRICT . .
~~~I~~~R1368
NUMBER 83
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 1 02 58 2 '175
2. RESIDENCE A. NV B. r"\t If,..hCCQ
ISTATE) '"1crjBI?I?)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
MD .
SPECIFY Poughkeepsie
o STREET ADDRESS 24 Delallergne Allenlle ZIP 17590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..I[] NO
Mcl;l~ / ~O / ~~2
3. A. AGE 46
4. EMPLOYMENT
38. DATE OF BIRTH
A USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH ~ff.Il~~~t~'N!';JJsA)
6. FATHER
A NAME Harold N3con
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Patricia Brown
B. COUNTRY OF BIRTH U 53 A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH 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
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
53yl\6\5tL~nn ThlJr~~ENT SURNAME
..J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~m:N~~~~~t~~~~~~3son
o SOCIAL SECURITY NUMBER 099-48-4? R4
12. RESIOENCE A.NY B. D' ,t,..h",SS
(STATE) 1C'Cli'lNhl
C CHECK ONE 0 CITY 00 TOWN 0 VILLAGE
AND e b" .
SPECIFY 0119 1'\E'E'p'>IE'
o STREET ADtJRESS?4 np-I::!VF~rgnp. Avp.nlJp. ZIP 1 ?590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES olJ NO
13. A. AGE 58 3B. DATE OF BIRTH ~~NTH /()~AY ~ ~~~
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH PQllnhkp-PLJn~ip:.., NY
(CITY, ~ATE I co NTRY IF NOT USA)
16. FATHER
A. NAME Alvah William Th'lrber
B. COUNTRY OF BIRTHH nil::! nrl
17. MOTHER
A. MAIDEN NAME Fli7::!hp-th I nlli~p- KI::!p-r
B. COUNTRY OF BIRTHII ~ A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
o
(3) 0 DIVORCE
DEATH
n
B. HOW DID LAST MARRIAGE END?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
ledge and belief that the information I prOVided is true and that I declare that no legal impediment exists
22. SIGNATURE O~ USE CURRENT NAME
~ _.._-~
OATE 07/09/2008
21. SIGNATURE OF GROO~
L..)
23. SUBSCRIBED AND SWORN TO/AFFIRMED BE
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
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
NAME (PRINT)
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{ SEAL }
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WN
by New York Domestic
25. B SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON,
TIME
MONTH
YEAR
MONTH
DAY
YEAR
DAY
AM
01 :33PM
07 2008
07
10
2008
09
STR
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
OXRELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
p(.CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY POL.l~kkel:O!f;~ IJ Y
TITLE ASSoc.c.;k M.iN\,S-+v-
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