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COUNTY Dutchess
CITYfTOWN Wappinger
~~J~~c; 1368
~G~I;~~R 51
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
n::lrr~1I I ~~ Sm::lrt
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Marc~D~perrice B~~~[,}T SURNAME
~
1. 'A FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 063-58-0679
2. RESIDENCE A. NY 8. nlltr.h~!=:!=:
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 5 Wildwood Drive: Apt 2C ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3 A, AGE 44 3B. DATE OF BIRTH 11 / 1 R / 1 ~R~
MONTH DAY YEAR
4. EMPLOYMENT
A, USUAL OCCUPATION NYS C:nrr~r.tinn!=: Offir.~r
B. TYPE OF INDUSTRY OR BUSINESS Corrections
5, PLACE OF BIRTH Manhattan NY
(CITY, STATE / COUNTRY IF NOT USA)
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Sma rt
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 096-58-2920
12 RESIDENCE A, NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 1tI TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDREss5 Wildwood Drive; Apt 2c
ZIP 12590
DYES '6 NO
A971
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A. AGE ~R 3B. DATE OF BIRTH 10 /'f 5
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION NYS Corrections Officer
B. TYPE OF INDUSTRY OR BUSINESS Corrections
15. PLACE OF BIRTH Cortlandt. NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A, NAME Unlisted
'B. COUNTRY OF BIRTHUn listed
6. FATHER
A. NAME Oti~ I PI=' Sm~rt
B. COUNTRY OF BIRTH USA
7, MOTHER
A. MAIDEN NAME Dorothy Flizabeth Yates
B. COUNTRY OF BIRTH LJ S A
B. NUMBER OF THIS MARRIAGE 2
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
100
B. HOW DID LAST MARRIAGE END? (3) 1!1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
c. DATE LAST MARRIAGE ENDED? 07/?R / 1 ~~~
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [!"yES 0 NO
17. MOTHER
A. MAIDEN NAME Jacqueline Denise Brown
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
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C, DATE LAST MARRIAGE ENDED? / (.
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
YEAR
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) ICITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
07/?R/1 ~~~ Rronx, Ny 0 1ST 0 0
o 2ND 0 0
o 3RD 0 0
o UH 0 0
d belief that the information I provided is true and th t I declare that no legal impediment exists
1ST
2ND
3RD
4TH
I duly swear/affirm, depose a
as to my right to enter into t
w
en
z
w
o
::i
USE RR NT NAME
23. SUBSCRIBED AND SWORN TO/A FIRMED BEFORE ME
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 !l11 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
05/16/2008
~
{ SEAL }
~
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
10:28AM
PM
05
17
2008
07
15 2008
STATE
27, TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
WN
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICAT
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B, COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
wi","" <<t ~
SIGNATURE~