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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M{l~ew Kipp AJ~r~
I LE C € SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~ 1368 .
~~~I:~~R 117
L. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 0"0 64 1614'
D. SOCIAL SECURITY NUMBER _~_- --- - ---
2. RESIDENCE A, N Y B. n..tr-hA!'::!'::
(STATE) lCOUNTY)
C. CHECK ONE 0 CITY [iI' TOWN 0 VILLAGE
AND P hk .
SPECIFY Ollg AApSIA
D. STREET ADDRESS 26 Cooper Road, Apt. 705 ZIP 12603
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!!! NO
3. A. AGE 27 3B. DATE OF BiRTH 09 / ?7 / 1 Q79
MO~ D~ YEA~
4. EMPLOYMENT
A. USUAL OCCUPATION r.~rrAntAr
B. TYPE OF INDUSTRY OR BUSINESS Idema Construction
5. PLACE OF BIRTH Citv Of Pouahkeeosie, New York
(CITY. !'TATE I COUNTRl7"F NOT USA!
6. FATHER
A. NAME .John Virgil AIIArs
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Elizabeth Parmele Gilbert
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE.. .... .. __.n... .ClvlL 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
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
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
r.hr~'7J'~~~ I ynn ~af;1~~ SURNAME
.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE AllAr!'::
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 134-68-1070
12. RESIDENCE A. NY B. nlltchASS
(STATE) (COUNTY)
C. CHECK ONE 0 CITY [j" TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREET ADDRESS 4203 Cherry Hill Drive ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
O~ /?6 A 9AO
MONTH DAY YEAR
13. A. AGE ?7
3B. DATE OF BIRTH
14. EMPLOYMENT
A.' USUAL OCCUPATION Customer Service Rep
B. TYPE OF INDUSTRY OR BUSINESS C. I. A.
15. PLACE OF BIRTH Rhinebeck. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Kevin J Wager
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lori Ann Davis
B. COUNTRY OF BIRTH USA .
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. '.- YEAR
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 1ST
o 2ND
o 3RD
o 4TH
lief that the information I provided is true
o
o
o
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say, that to the best of
as to my right to enter into the marnag~ . .
21.SIGNATUREOFGROOM~ fY7~~
USE CUR ENT ME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This Iicsnse authorizes the marriage in New York State of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York 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.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) J C. Master
TIME MONTH DAY YEAR MONTH DAY YEAR
SEAL SIGNATURE ~ DATE 09/12/200
"-- .-.J MAILW~ ~PIRF!l~e AM
--v- LU Mlam h Rd, Wappingers Falls, NY 12590 03:54>M 09
STREET CITYITOWN STATE ZIP
~~~R~~RT~~J 10~0~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
13
2007
11
11 2007
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED r (
A. STATE NEW YORK B. COUNTY 1), t{..j\1:..5.J,.
TITLE 7~~
DATE ? It, Iv ':f-
/U
ST TE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF IE TOWN OF tP VILLAGE OF
SPECIFY ;-I{ de (If. ri.