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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Lawrence Euqene Gault, II
FIRST MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~:fRT 1368
~~~~~~R 43
--.J
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Danielle Marie Ward
11. A FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
Q.
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE Gault
(OPTIONAL - SEE REVERSE) 073-74-5760
D SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D TOWN I!'l VILLAGE
~~~CIFY WapPin~ers Falls
D STREET ADDRESs41 pring Street, Apt. B ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 6 YES D ND
~O /f979
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 120 62-7422
D. SOCIAL SECURITY NUMBER -
2 RESIDENCE A. NY 8. Dutchess
(STATE) (COUNTY)
C CHECK ONE D CITY D TOWN oC VILLAGE
~~~CIFY Wappinqers Falls
D STREET ADDRESS 41 Spring Street, Apt. B ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES D NO
04 /26 /1974
DAY YEAR
09
13 A. AGE 28
3. A. AGE 34
38. DATE OF BIRTH
38. DATE OF BIRTH
MONTH
DAY
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
5. PLACE OF BIRTH City Of New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Lawrence Eugene Gault
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Catherine Tully
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Docent
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH Cold Spring, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William Kendall Ward
'8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nancy Alma Lee
B COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / ~
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
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
D
D
D
D
nt exists
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the
21. SIGNATURE OF GROOM~
1ST
2ND
3RD
4TH
at the information I provided is tru
';t::.. 22. SIGNATURE OF BRIDE ~
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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) John
TIME MONTH YEAR
SEAL SIGNATURE ~
MAILING ADDRESS
~ 20 Middle
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29 OFFICIANT~
NAME (PRINT) q-A<:::
DATE
by New York Domestic
MONTH
YEAR
07
01 2008
05
03
2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~C(,'Tt ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
NAME (PRINT) ..
SIGNATURE~
[')n'-'.QR In'l/?oom
NAME (PRINT)
SIGNATURE~