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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Char~%L~oseph G~~pJiRNAME
B. BIRTH NAME, IF DIFFERENT Charles Joseph Abrams
I
STATE FilE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
COUNTY Dutchess
CITYITOWN Wappinger
~~~:~; 1368 .
~~~I~~~R 1 2
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
n~m~flS!lf Ann RA~~YBJT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ,
D SOCIAL SECURITY NUMBER 114- 7 O-OR 1 fi
2. RESIDENCE A N'fsTATE) B. I:?c~ess
C. CHECK ONE 0 CITY 0 TOWN.,jZ] VilLAGE
~~~CIFY W::!rrinaAr~ F::!II~
D. STREET ADDRESS ?RR8 West M~in Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
MO;W /:1J / y1;F9
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. s~S~*~M~~~rt~~b~~s~alli pol i
D. SOCIAL SECURITY NUMBER 10fi-7?-9904
12. RESIDENCE A. NY B. rllltrhE'S~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN Iij? VILLAGE
~~~CIFY W::!ppingArs F~lIs
D. STREET ADDRESS 2668 West Main Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? !ii!l YES 0 NO
nR . /01 /1QR2
1>f0liiTH DAY ~m
13. A. AGE 25
3. A. AGE 28
4. EMPLOYMENT
A. USUAL OCCUPATION Police Officer
B. TYPE OF INDUSTRY OR BUSINESS I ~w Fnfnrr.,:om,:ont
5. PLACE OF BIRTH Smitl1town NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION EVAnt Conrrlin::!tnr
B. TYPE OF INDUSTRY OR BUSINESS Hnspit~lity
15. PLACE OF BIRTH r.itv Of PnllnhkAAosie, NY
(CITY:STATE / COUNT~ IF NOT USA)
16. FATHER
A. NAME TerrancE' Andrew RE'\lE'1I8
'B. COUNTRY OF BIRTH l J S A
17. MOTHER
A. MAIDEN NAME Fr::!nr.ine Ann H~miltnn
B. COUNTRY OF BIRTH l J S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
~
:>
<C
C
u:::
A. NAME Jos~ph P.ul Abrams
B. COUNTRY OF BIRTH I I ~ A
7. MOTHER
A. MAIDEN NAME Sandra OriE'ttc Wnng
B. COUNTRY OF BIRTH Gllatemala
8. NUMBER OF THIS MARRIAGE ?
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE ~.GIVIL-ANNULMENT
DEATH
o
o
o
1
o
B. HOW DID LAST MARRIAGE END? (3) rfil! DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / 16 / ?n08 '
MONTH DA~ 'irA'!\'
D. ARE ANY FORMER SPOUSE(S) ALIVE? [VIYES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION 20.
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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
..
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 01/16/2008 Goshen, New York
2ND
3RD
o
o
o
1ST
2ND
3RD
o
o
o
o
o
o
23. SUBSCRIBED AND SWORN TO/AFFIR BEFOR
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 911 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
DATE
n3/05/2008
by New York Domestic
~
{ SEAL }
'-..r-'
NAME (PRINT)
MONTH
YEAR
YEAR
MONTH
2008
05
04 2008
03
06
A E
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 1'5- VILLAGE OF
SPECIFY tlj1T.fJf/rI~IZ':)~ FItL.i..';;
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PEA-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT /
NAME (PRINT)
~ CIVIL
28. PLACE WHERE MARRIAGE OGCURRED
A. STATE NEW YORK B. COUNTY4'~('Af-~"'"
TITLEAc/iIl.;-v{u..~~mU!!:
/.., DATE ~~ ~ :~od$:
tH~/lv~J' ~g 1/ f!. I.2SCK (:)
STREET CITY OWN STATE ZIP
30 WITNESS TO CEiR~ONY . / ~. . ,...... 31. WITNESS TO CEREMONY
NAME(PRINT) ~/V; ~ Ii;- /'\.e-\ ~t-1-A- NAME (PRINT) Slnt.~PJ<.J~7 ~1it3iZr?-IJ,l">
SIGNATURE~ C/"p" r.w.p./~ SIGNATURE~--==~J~7'/~~?Z~(
DOH-9B (03/2006) I ____--