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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c.;r 1368
~~~~~~R 19
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rri;:m S (;rn~~
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Elizabeth Ann PODe
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Pope-Gross
(OPTIONAL, SEE REVERSE) 058 66 0233
D. SOCIAL SECURITY NUMBER --
12 RESIDENCE A. NY B Dutchess
1ST ATE) (COUNTY)
C. CHECK ONE 0 CITY!i"'l TOWN 0 VILLAGE
AND W .
SPECIFY applnger
o STREET ADDREss24E Winthrop Court
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)
D. SOCIAL SECURITY NUMBER 098-64-8711
2. RESIDENCE A. NY B. nlltr.hp.~~
(STATE) (COUNTY)
C CHECK ONE 0 CITY oiJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D STREET ADDRESS 24E Winthrop Court ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR iNCORPORATED VILLAGE? 0 YES ~ NO
08 / O~ / 1 qRn
MONTH DAY YEAR
ZIP 12590
DYES~NO
/f 981
YEAR
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE /R 3B. DATE OF BIRTH 08' /12
MONTH DAY
3. A AGE 2.7
3B. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION I n~n Arlmini~tr~tnr
B. TYPE OF INDUSTRY OR BUSINESS Finance
5. PLACE OF BIRTH Rrnnx NY
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Newburgh
15. PLACE OF BIRTH Carmel. NY
(CITY, STATE / COUNTRY IF NOT USA)
6, FATHER
16. FATHER
A. NAME Erik Scott Pope
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Patricia Ann Bouton
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
n 0
DEATH
o
A. NAME Neil Simon Gross
B. COUNTRY OF BIRTH l J S A
7. MOTHER
A. MAIDEN NAME S~nrlr::l Hp.lp.n Fp.inman
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
'DIVORCE' ~.... ',' ." "'CI\7ILANNULMENT
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, that to the best of my kno
as to my right to enter into the mamage state.
.!.'.:,'
o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
dge and belief that the information I provided is true and that I declare that no legal impediment exists
<:.,
21. SIGNATURE OF GROOM~
DATE
03/19/2008
---
=:::>
22, SIGNATURE OF BRIDE ~
USE CURRENT NAME
w
en
z
w
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::i
USE RR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y 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,
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
~
{ SEAL}
'-v-'
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
AM
06:37PM
18 2008
20
2008
05
03
TATE
27. TYPE OF CEREMONY
O~L1GIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE A~ECIFY)
o CITY OF ts TOWN OF 0 VILLAGE OF
SPECIFY v1tPPI/J GtR 5
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER,
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY:Dv TZtffS
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~