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COUNTY f)LJtchess
CITYn-OWN Wappinger
~~~:~~ 1368
~~~I~;~R 59
STATE OF NEW YORK
DEPARTMENT OF HEALTH
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Timotb~DLJOC;E'ph li'6JM~yluRNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
V;::!lerie M;::!rie McG;::!rrv
MIDDLE CURREFiT SURNAME
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE .limene7
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 054-68-3036
12, RESIDENCE ANY B,Rnr.kl;::!nd
(STATE) (COUNTY)
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
~~~CIFyStony Point
D STREET ADDRESs9 Tom kins Ridae Road
ZIP 1 0986
DYES..o NO
j(q8:1
YEAR
~
:;
<(
c
u:
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 068-68-/1')7
2. RESIDENCE A N'(STATE) B ~g~fnd
C CHECK ONE 0 CITY..lJ TOWN 0 VILLAGE
AND "'t P'
SPECIFY ;-, nny nlnt
D STREET ADDRESS 9 Tomkins Ridge Road ZIP 10986
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
3. A AGE 26 3B. DATE OF BIRTH M~~ / dJ / JE~R81
4, EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Ret;::!il
5. PLACE OF BIRTH Rrnn)( Np.w Y nrk
(CITY, STAtE / COUNTRY IF NOT USA)
6. FATHER
A NAME Dalfid Jimenez
B. COUNTRY OF BIRTH II ~ A
7, MOTHER
A MAIDEN NAME T p.rri Ann .I;::!mes
B. COUNTRY OF BIRTH I I ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED.BY
DIVORCE CIVIL ANNULMENT
DEATH
o
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
06 Ab
MONTH DAY
13. A. AGE?5
3B. DATE OF BIRTH
14. EMPLOYMENT
A, USUAL OCCUPATION Hnmem;::!ker
B. TYPE OF INDUSTRY OR BUSINESS Homemaker
15. PLACE OF BIRTHManhattan, New York
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A NAMEWilli::lm Frlw;::!rrl Mr.(.;;::!rry
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A, MAIDEN NAME Ann Marie Braniff
B COUNTRY OF BIRTJJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
o
o
DEATH
n
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
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
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, depose and say, that to the b st of
as to my right to enter into the ~ge state.
21. SIGNATURE OF GROOM~ /--:. ,
o 0 1ST 0 0
o 0 ~D 0 0
o 0 3RD 0 0
o 0 4TH 0 0
y knowledge and belief that the information I provided is true and that I declare that no e al impediment exists
22. SIGNATURE OF BRIDE~ U ~
USE CURRENT NAME
DATE
06/04/2008
w
en
z
w
o
::i
23. SUBSCRIBED AND SWORN TO/AFFIR B OR
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 Slate. 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)
MONTH
by New York Domestic
~
{ SEAL }
'-..t-I
YEAR
YEAR
TIME
MONTH
AM
ZIP 12:47 PM
1~L
06
05
2008
08
03 2008
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
WN
STREET
1 CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED (
A. STATE NEW YORK B. COUN-i;>"" ~( \...1.> S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY\JJ it ~ P \ IV G-e l