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1. A. FULL NAME
;:) I P. I C. Ur- I~C. VV Y UHf\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Stp.php.n Stp.rling Masten Jr
FIRST MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYffOWN Wappinger
~~~:~c~ 1368
~~~~~~R 22
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kristen Lee Smith
MIDDLE CURRENT SURNAME
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11. A. FULL NAME
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Masten
(OPTIONAL - SEE REVERSE) 7 70 1160
D. SOCIAL SECURITY NUMBER 12 - -
12. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!"l TOWN 0 VILLAGE
AND W .
SPECIFY apOlnger
D. STREET ADDRESS 3 0 Baldwin Drive
,B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 054-60-5937
2. RESIDENCE A. NY B. nl Jtr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY o,Ii'J TOWN 0 VILLAGE
AND P hk .
SPECIFY nug eepsle
D. STREET ADDRESS 18 Marino Road ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 31 3B. DATE OF BIRTH 10 / nq / 1 q7R
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE 3? 3B. DATE OF BIRTH 07 ./11
MONTH DAY
ZIP 12590
DYES tJ NO
/1'975
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Con~tn Idinn \^,nrkp.r
B TYPE OF INDUSTRY OR BUSINESS Building
5. PLACE OF BIRTH MOl mt Ki~r.n Np.w York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A NAME StepheJ'1 Sterling 1\JI::I~tp.n
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A MAIDEN NAME N::Inr.y I P.P. Snnwrlnn
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH Yonkers, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Maurice Smith
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Emily Frances Betz
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
n 0
DEATH
o
DEATH
n
(2) 0 DEATH
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
~
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
o
o
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the marnag
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
st of my knowledge and belief that the information I provided is true
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23 SUBSCRIBED AND SWORN TO/A6 IR D BEFORE
SIGNATURE OF TOWN OR CI L K ~ DATE
This license authorizes the arriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform rriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o hecked, this license is to be used only for the purpose of a second or subsequent ceremony.
24, TOWN OR CITY CLERK
r-^-"
{ SEAL }
'-.t-I
25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRIN1)
SIGNATURE ~
MAILING ADDRESS
YEAR
MONTH
YEAR
TIME
MONTH
AM
03:37PM
05
24 2008
2008
03
26
TATE
27. TYPE OF CEREMONY
o I!I'1iELlGIOUS
9 0 OTHER, SPECIFY
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYl)~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY ~ ~
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
10 CIVIL
30. WITNESS TO~C EMONY~~
NAME(PRINT) ~M_.~~___
SIGNATURE~ ~A
DOH-98 (03/2006)