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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c~ 1368 .
~~~I:J~R 11
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mar~D~L~"'E'C::: Ir\li~J~LuRNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Me~~~n M McN~UlENT SURNAME
~
1 . A FULL NAME
11. A. FULL NAME
FIRST
FIRST
Q.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I r\lino
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 115-76-8505
12. RESIDENCE A. NY B. nlltr.hess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN IZl VilLAGE
~~~CIFY Wappingers Falls
D. STREET ADDREss40 Prospect Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
10 . An A~R~
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIALSECURITYNUMBER 074-7R-0103.
2. RESIDENCE A. N'lsTATE) B. qc'tlbWss
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
AND \^/ .
SPECIFY ::Irrmopr
D STREET ADDRESS 1? Seneca Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A AGE 24 38. DATE OF BIRTH MOQ~ / Q..?- / -ki83-
4. EMPLOYMENT
A USUAL OCCUPATION Steamfitter
8. TYPE OF INDUSTRY OR BUSINESS r.nnc:::tn lr.tinn
5. PLACE OF BIRTH POllnhkeE'nr;iE' Npw Y nrk
(CITY, MATE / COUNTRY IF'NOT USA)
6. FATHER
A. NAME Mark James In'ing II
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Nicola lanE' P~r;by
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 CIVIL ANNULMENT
DEATH
o
13. A. AGE 22
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION r.::!c:::hier
B. TYPE OF INDUSTRY OR BUSINESS Retail
15. PLACE OF BIRTH Smithtown, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Mich8el 1\J1r.Npill
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Wenrly McCue
B. COUNTRY OF BIRTH l J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
_DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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
w
en
z
w
o
::;
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, depose and sa at tO~tteh..e b st of y knowledge and belief that the information I provided is tr4;ue. and ~that I deCla~re that no Iceg4al im.~pedliment exists
as to my right to enter into the
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~ ~ -
~SE C ENT NAME C; "USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ,.. .1/ Y11 ...., ~ ,<<... O?/?'"'/?oon
SIGNATUREOFTOWNORCITYClERK~ _!:. _/~ DATE ____tl____D
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o " 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
,-I'-..
{ SEAL }
~
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
DATE
02/2Q/2008
AM
01 :20PM
03
01
2008
04
29 2008
p
SA
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
l~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~CJf13&
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY 00 fl'rPP J ~ ~
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.