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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~: 1368 .
~~~I~~~R 9
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1~~~5, Thnm::l~ c~~lM,. SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
An rip. n ~~o~ i r.nlp. \/ p.160~R~Mt~NAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIOEN NAME), IF OIFFERENT
C. SURNAME AFTER MARRIAGE I-IIIY
(OPTIONAL - SEE REVERSE) 1 09 74 2208
D. SOCIAL SECURITY NUMBER - -- - -- - ----
12. RESIDENCE A. NY B [llltr.hp.!,:S
(STATE) (COUNTY)
C CHECK ONE 0 CITY!l TOWN 0 VilLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 1 F Surrey Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES I51f NO
13. A. AGE 24 3B. DATE OF BIRTH n~ Lj 7 A QR3
Mo'N'TH' dAY IDA
B. BIRTH NAME, IF OIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) .
D. SOCIALSECURITYNUMBER 110-72-7876
2. RESIDENCE A. NY B [)lltr.hp.!,:!,:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
AND W .
SPECIFY arpmger
D STREET ADDRESS 1 F Surrey Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3 A AGE 24 3B. DATE OF BIRTH MO~~ / 01) / y1283
4. EMPLOYMENT
A USUAL OCCUPATION I-Illrlc:nn \/::IIIAY r.hAm-rlry
B. TYPE OF INDUSTRY OR BUSINESS Clp.aning
5. PLACE OF BIRTH Rp.ar.nn Np.w Y nrk
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME Arthllr lOSE-ph I-IIIY
B. COUNTRY OF BIRTH l J S A
7. MOTHER
A. MAIDEN NAME R::lrh::lr::l ~rn!=;r.h::lnl
B. COUNTRY OF BIRTH I J 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 FYAr.lltivp. A!':!':i!':t::lnt
B. TYPE OF INDUSTRY OR BUSINESS Energy
15. PLACE OF BIRTH Citv Of Pnuohkeensie I NY
(CITY:STATE / COUNT/i'{ IF NOT USA)
16. FATHER
A. NAME .hllin \/P.1::I7(1'1P.7, .Ir
'B. COUNTRY OF BIRTH l J S A
17. MOTHER
A. MAIDEN NAME Shelley Grar.e Henge!=;
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
DEATH
o
o
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH OA Y 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
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
o
o
o
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provide
as to my right to enter into the marn tate.
21. SIGNATURE OF GROOM~
~SE C RR NAME
23. SUBSCRIBED AND SWORN TO F MED BEFOR r -' A
SIGNATURE OF TOWN ORCI LERK~ _'e:2!. '-lI...",
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.
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
22. SIGNATURE OF BRI
DATE
by New York Domestic
,-'-.
{ SEAL }
'-v-I
YEAR
MONTH
YEAR
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
TIME
MONTH
AM
02:41 PM
02
20
2008
04
19 2008
STATE
27. TYPE OF CEREMONY
o~ RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY MQ\E?7
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMEO ABOVE ON THE
DATE AND AT THE TIME ANO
PLACE INDICATED.
10 CIVIL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF E TOWN OF 0 VILLAGE OF
TITLE EPI?COPAL PR\E5T
SIGNATURE' DATE MARf-H zq I ZCOR
MAILING ADD ss
'54 M\"tQ\ELl.. A.\IE.~\jEl 0\-\'KEt:P.SIE J ~y 12&.03
STREET CITYrrOWN STATE
30. WITNESS TO C.J1REMONY
NAME (PRINT) fi ,
SPECIFY (JJA 'Pf'N0 ER:
SIGNAruRE~
DOH.98 (0312006)
ZIP
31. WITNESS TO CEREMO~Y .
NAME(PRINT)-1l~ ~
SIGNATURE~
.(