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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
r.hri!::~g~E R~rry H~ml!t~~URNAME
COUNTYD utchess
CITYfTOwNWappinger
~~~:~~1368 '
~~~~~~R11 8
1 , A, FULL NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEh
o SOCIAL SECURITY NUMBER 72-68-1462
2, RESIDENCEA,NC B, AI~m~nr.A
(STATE) (COUNTY)
C, CHECK ONE 0 CITY..cJ TOWN 0 VILLAGE
~~~CIFY Gibsonville
o STREET ADDRESS 1105 Long Leaf Drive ZIP 27249
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'I'tJ NO
3. A, AGE30 3B. OATE OF BIRTH OR / '0 /1 fJ77
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS Manufacturing
5. PLACE OF BIRTHPouahkeepsie. NY
(CITY. ~TATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Barry Douglas Hamilton
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Susan Ann Hait
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
BranM~tK~im COOIt~R~ENT SURNAME
~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
11. A. FULL NAME
FIRST
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. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE H~milton
(OPTIONAL - SEE REVERSE),.,
D. SOCIAL SECURITY NUMBER 127 -72-8933
12. RESIDENCEANr. BAlamance
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..cJ TOWN 0 VILLAGE
~~~cIFYGibsonville
D. STREET ADDRESs11 05 LonQ Leaf Drive
z,~7249
o YEs"'O NO
1-983
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE?
13. A. AGF?4 3B. DATE OF BIRTH 04 %1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIONCardiology
B. TYPE OF INDUSTRY OR BUSINESsMedical
15. PLACE OF BIRTHPoughkeeDsie, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEWilliam James Coogan. Jr.
'B. COUNTRY OF BIRTM S A
17. MOTHER
A, MAIDEN NAME Kim Beth Watson
B. COUNTRY OF BIRTM S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say,
as to my right to enter into the
"
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 D
o 0 4TH 0 0
y knowledge and belief that the information I provided i~ and that I declare thal no legal impediment eXists
22. SIGNATURE OF BRIDE~ ~.'J1~1 ^ J
~
DATE 09/12/2007
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFOR
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y State of he bride and groom named above by any person authorized
Relations Law !ill 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) Jo C. Masterson
{ 09/12/200 TIME MONTH YEAR
SEAL SIGNATURE ~, DATE 7
'-v-' M~1.Jfilrcffe appingers Falls, NY 12590 04:10 ~~ 09 13 2007 11
STREET CITYITOWN STATE ZIP
~~~R~~RT~~~ lo~O~~Ni?t~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIM MO. DAY YEAR 0 0 RELIGIOUS 1.fEJ"6VIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
by New York Domestic
W
U)
Z
W
(,)
::l
MONTH
YEAR
11 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ) i..J.* J o~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFYtA) ^ ff~ ~.p r