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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c; 1368
~~~I~;~R 55
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mir.h~MlEThnm::l~ ~~~~.pSURNAME
I"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
.Jp.ssica I \Jnn Coombs
MIDDLE J CURRENT SURNAME
~
1. ,A FULL NAME
11. A FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE R::Iti r::l
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 074-78-6617
12. RESIDENCE ANY B. Dl Itchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Beekman
D STREET ADDREss226 Darn Road
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER ORR-58-5054
2. RESIDENCE A. NY B. [Jlltr.hec::~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY I Jnionv::Jlp.
D. STREET ADDRESS 62 Darren Road ZIP 12540
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..a NO
3. A. AGE 38 3B. DATE OF BIRTH OR / 01 /1 q69
MO~ DAY YEAR
ZIP 12540
DYES '6 NO
A9R1
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?R 3B. DATE OF BIRTH 07 /.54
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Educator
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH White Plains New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMECh::Jrlp.s Frp.drick Coombs III
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Linda Ann Lisi
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
.-
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<C
Q
4. EMPLOYMENT
A. USUAL OCCUPATION Edllr.::Itnr
B. TYPE OF INDUSTRY OR BUSINESS Education
5. PLACE OF BIRTH POllahkp.p.n~ip. Np.w York
(CITY, ~ATE / COUNTRY IF NOT USA)
6. FATHER
A NAME Thom::l~ Anthnny R::Itir::l
B. COUNTRY OF BIRTH l J S A
7. MOTHER
A. MAIDEN NAME Di::Jnp. I OUiSp. Granp.y
B. COUNTRY OF BIRTH LJ S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
~
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
0:'
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the m
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
nowledge and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE~ (\Q/v)~--L ';;f. (J-~
... ~CURRENTNAME
DATE OS/27/2008
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEF
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 ~11to 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}
'-v-I
NAME (PRINT)
SIGNATURE.
MAILING ADDRESS
YEAR
MONTH
DAY
YEAR
TIME
MONTH
AM
02:54PM
05
28
2008
07
26 2008
STATE
27. TYPE OF CEREMONY
o ['g., RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~Uje I-t 0ss
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY fA) 4- P P I 'N Ci (:7 e~ ffl-ll.s.
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
~ ~bDl'
bs
TITLE Pt:lyO(..~;c" \
SIGNATURE.
MAILING !,-DDRESS
1\ tx..lY1+cn S t
STREET
30. WITNESS TO CEREMONY
DATE
f", 'l <>
31. WITNESS TO
NAME (PRINT)
SIGNATURE.
1"\ CI26(1)
NAME (PRINT)
SIGNATURE.
~