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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ro@~tl Mark W~~~QT SURNAME
This license authorizes the marriage in New 0 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
COUNTY r1utchess
CITYfTOWN Wappinger
~~~::oc: 1368
~~~I~;~R 66
1 . A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER n73-n4-~ 173
2. RESIDENCE A. NYsTATE) B. qc~~~ess
C CHECK ONE 0 CITY oil] TOWN 0 VILLAGE
AND \^/ .
SPECIFY ~rrlnoer
D. STREET ADDRESS 15 Middlebush Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MO~Tt / rR~ / y1i64
3. A. AGE 43
38. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Operatina Enginl">er
B. TYPE OF INDUSTRY OR BUSINESS (:nnstn Idinn
5. PLACE OF BIRTH r.hir.nDPp MA
(CITY, STAtE I COUNTRY IF NOT USA)
6. FATHER
A NAME Mark Aller Wilc;on
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME r1i~n::l I nllise Vnn Hnfe
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 2
9. ~R~~~~~RM6'f~/:('&Tc5us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
o
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09/ 11 / 1 qqR
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [Y"vES 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
nq/11/1 qqR nlltr.hess (:01 mty New 0 f'i!J'
o 0
o 0
1
1ST
2ND
3RD
4TH
I duly swear/affirm, depose an
as to my right to enter into th
21. SIGNATURE OF GROOM~
w
(IJ
Z
W
o
::::J
~
{ SEAL }
'-v-I
NAME (PRINT)
ti:~z w
~;:2
lJ! ~ ~!;( 29. OFFICIANT
tii ~ S 0 NAME (PRINT)
:OUUJ
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~ffi~ ~
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01->
w~~ 0
....mlO
~3!;
SIGNATURE~
n()~_QA m~l?nnfn
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A FULL NAME FIRST (:::ltt;t~r A nn Ne~~EliENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT \Ie rs a ce
C. SURNAME AFTER MARRIAGE \^'ilsOJ1
(OPTIONAL - SEE REVERS~I
D. SOCIAL SECURITY NUMBER 050-56-9098
12. RESIDENCE A. NY B [Illtr.heSS
(STATE) (COUNTY)
C. CHECK ONE 0 CITY III TOWN 0 VILLAGE
AND W .
SPECIFY arrlnger
o STREET ADDRESS 15 Middlebush Rd
13. A. AGE 39
ZIP 12590
DYES tJ NO
/'fqR8
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
09 ~9
MONTH DAY
38. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION T e::lr.her
B. TYPE OF INDUSTRY OR BUSINESS Wcsd
15. PLACE OF BIRTH Reacon, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Fr::lnr.is .11 IlillS \/ers::lr.e
'8. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Janet Ruth Van Wagner
B. COUNTRY OF BIRTH LJ S A
1 B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 n n
B. HOW DID LAST MARRIAGE END? (31 [!I'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 1? / ?? / ?nO~
MONTH DA Y ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~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
1 ST 12/22/2005 Dutchess County, New 0
~D 0
3RD 0
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
AM
04:10PM
06
12
2008
08
10 2008
ZIP
1~~L
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY J;i'iiC.w
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY w~IV€~M ~