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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c; 1 368
~~~I:;~R 4
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
ArthuJID~~oenix M~~~~ !~RNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sarah M Smith
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Smith-Moore
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 111-72-3085
12. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 120 New HamburQ Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES I!l' NO
/?6 /f 985
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 440-96-6848
2. RESIDENCE A. OK B. Osaae
(STATE) (COliN'R')
C. CHECK ONE olJ CITY 0 TOWN 0 VILLAGE
~~~CIFY Tulsa
D. STREET ADDRESS 1730 West Independence ZIP 74127
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? I!l' YES 0 NO
O~ / 20 / 1986
MONTH DAY YEAR
3. A. AGE ?1
13. A. AGE 22
3B. DATE OF BIRTH
07
MONTH
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Photographer
B. TYPE OF INDUSTRY OR BUSINESS Freelance
5. PLACE OF BIRTH Tulsa. Ok
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Arthur Phoenix Moore
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Fannye Mae Abair
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER.OF f'EIEYlQUS..MARBIAGES WHICH. ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH Cold Spring. NY
(CITY. STATE / COUNT~Y IF NOT USA)
16. FATHER
A. NA~E Louis Robert Smith
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Erin Marie De Mers
B. COUNTRY OF BIRTH U S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
DEATH
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
1ST
2ND
3RD
o
o
o
o
o
o
o
o
o
w
C/J
Z
W
()
::::i
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 ~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
NAME (PRINT)
YEAR
DATE
01/16/?OOR
by New York Domestic
~
{ SEAL }
'-r-I
DATE 01/16/?OOR
TIME
MONTH
YEAR
MONTH
01
17
2008
03
16 2008
WN
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER. SPECIFY
28. PLACE WHERE MARRIAGE OC~_
A. STATE NEW YORK B. COUNt!~'V GJk.I.b
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY .~!,... -...:T"'c.-;---
E'A,r .c5J.lk'LL
SIGNATURE~
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~