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COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT
~~~I~~~R 1368
NUMBER 71
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JOG~~EDOn3Id ~~ISURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M i chelliDbt~ig h H iI delJw!it\fYlRNAME
~
1 . 1:-. FUll NAME
11. A. FUll NAME
FIRST
FIRST
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C S~S~~~oE~r-~~~EA~~b~~stt a mel
D SOCIAL SECURITY NUMBER 127-7?-75Rn
12. RESIDENCE A. NY B. D,.tl"h",ss
(STATE) fC15mln'i
C. CHECK ONE 0 CITY 0 TOWN l;tl VILLAGE
~~~CIFY \^'appif'l9E'rs Falls
D STREET ADDREss!1::\n!1 Prinr.p.~~ C':irr.lp. ZIP 1 ?590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 26 3B. DATE OF BIRTH Q~H /{)dAY -1 ~,
14. EMPLOYMENT
A. USUAL OCCUPATION T eaC'her
B. TYPE OF INDUSTRY OR BUSINESS Frlllr.;:\tinn
15. PLACE OF BIRTH Cit\l Of Pnllnhkp.p.n~ip.
(CIW STATE / COUNT~ IF NOT USA)
16. FATHER
,A. NAME Da\lid Wayne Hilderbrand
B. COUNTRY OF BIRTH I J ~ A
17. MOTHER
A. MAIDEN NAME lill I nlli~p \Np.irlnp.r
B. COUNTRY OF BIRTH II ~ A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 05<1 7<1 2031
2. RESIDENCE A. NV B. !""I. .+.--hee;e;
('sTATE) ~,
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
AND .
SPECIFY VVapplngers Falls
D STREET ADDRESS 5305 Princess CirclE' ZIP 1 ?!1gn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? iii1'I YES 0 NO
MO~ /:Ii / y1.ij79
3. A. AGE 28
4. EMPLOYMENT
3B. DATE OF BIRTH
A USUAL OCCUPATION Merchandise Handler
B. TYPE OF INDUSTRY OR BUSINESS Gap, Inc
5. PLACE OF BIRTH ~1",YsTg[,~09iWilJ~~~R~ie
6. FATHER
A. NAME H:3rvey Charles Hamel
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Anne Cecile Desrochers
B. COUNTRY OF BIRTH U S P.
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
DEATH
n
DEATH
o
(2) 0 DEATH
o
o
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
~
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
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
1ST
2ND
3RD
4TH
I duly swear/affirm, clepose and say, that to the best
as to my right to enter into the JllMIage state. .
21. SIGNATURE OF GROOM~
o 1ST 0 0
o 2ND 0 0
o ~D 0 0
o 4TH 0 0
lief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE~ ~~lli-\..f I I, OrIJ,U /-Jll0fl. ~
USECU~
DATE 06/16/2008
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFOR
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
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON,
~
{ SEAL }
'-.,-I
NAME (PRINT)
YEAR
MONTH
DAY
YEAR
TIME
MONTH
AM
01 :20PM
15 2008
06
17
2008
08
1~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY /J)tf)(p'55:.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~F ~LAGE OF
SPECIFY LJ)911 / '!J'f' r
29. .OFFICIANT
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~