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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST DO'lgl~L't/illiam H~l~~~t\ SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COu~lltchess
CITYfTowWappinger
~~~:~1f 368 .
~~~~J~~ 28
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nicnle M::Irie I ::IR::Irne
MIDDLE a:JRRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEi)
D. SOCIAL SECURITY NUMBER 1 31-60-7135
2. RESIDENCE iN Y B.nllt,.hpc:s
(STATE) '"'(C'a1jNTY)
C. CHECK ONE 0 crr~ 0 TOWN 0 VILLAGE
~~~cIFYRe::lcnn
D. STRm ADDREs29F Hudson View Drive zIP12508
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VilLAGE? 0 y~ 0 NO
3. A. AG60 3B. DATE OF BIRTH QD~ /2ly -1 ~Jl
4. EMPLOYMENT
A. USUAL OCCUPATlol'$ales 1\II:::m::lopr
B. TYPE OF INDUSTRY OR BuslNEsMlestern Tool Supply
5. PLACE OF BIRT~itv Of PnlJnhkeeosie
ICrrv, STATE / COUPffil"YIF Not USA)
6. FATHER .
A. NAME:\Nilli::lm nnllol::l~ Hnclltt
B. COUNTRY OF BIRn-!. J S A
7. MOTHER
A. MAIDEN NAME P::Itrice Cnnstance Copeland
B. COUNTRY OF BIRTHl J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE ~_._.___-CIVIL_ANNULMENT.
o 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGt-I nClltt
(OPTIONAL - SEE REVERS~)
D. SOCIAL SECURITY NUMBER 21-64-2138
12. RESIDENCE~ Y li)utchess
(STATE) (COUNTY)
C. CHECK ONE 0 ClnI"'O TOWN 0 VILLAGE
~~~cl~eacon
D. STREET ADDRESl9F Hudson View Drive
z~2508
o yF!t 0 NO
11'(81
YEAR
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE?
13. A. AGf6 3B. DATE OF BIRTH Ofi 14'
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCuPATloGr~phic Designer
B. TYPE OF INDUSTRY OR BUSINESIN Y H. R. C.
15. PLACE OF BIRTl?ouahkeepsie. New York
(c'iTY.' STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAM~On::lld .IosephLaBarge
'B. COUNTRY OF BIR-W S A
17. MOTHER
A. MAIDEN NAM&lennifer Ellen Horky
B. COUNTRY OF BlmIJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
.DWORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH ..~.. .
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
..- YEAR
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) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
0;:'
w
!i
=>
Z
Q
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w
~
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose n
as to my right to enter into
21. SIGNATURE OF GROOM
1ST
2ND
3RD
4TH
the information I provided
This license authorizes the marriage in New Yorl< State of t authorized by New Yorl< Domestic
Relations Law ~11 to perform marriage ceremonies within New Yorl< te. 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.
r-I'-. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J 0
{TIME MONTH DAY YEAR MONTH DAY YEAR
SEAL SIGNATURE~ DATE10/01/2007
MAIUNSiJ..IDPd 8:25 AM
"-v-' LU Mloe i eJ;S Falls, NY 12590 0 02 2007 1 30 2007
STREET CITY/TOWN STATE ZIP PM
~~~R~~RT~~J 10~O~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 7. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIM M. DAY YEAR 0 IX RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 3:30 PM 10-19-2007 900THER,SPECIFY
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Dutchess
29. OFFICIANT D i 1 d
NAME (PRINT) an e B. War
SIGNATURE~ ~~
MAILING ADDRESS
~r Tnhn'" T "theralJ ~_ch
STREET CI
30. WITNESS TO CEREMONY
NAME (PRINT) Sean
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
XI CITY OF 0 TOWN OF 0 VILLAGE OF
TITLE PaRtor
10-19-2007
DATE
SPECIFY Poug:hkeeps ie
NY 12603
55 Wilear Eo~~ara, Pou8hk88~~i
SIGNATURE~
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~
31. WITNESS TO CEREMONY