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COUNTY Dutchess
CITYfTOWN Wappinger
~~~::,c; 1368 .
~~~I~J~R 116
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rir.OliMP .Iohn RI~~R~~JJSURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Gilli;:Jn Isaacs Hemminas
MIDDLE CURREili'f SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 131-48-6705
2. RESIDENCE A. sn B. PF!nningtnn
(STATE) (COUNTY)
C. CHECK ONE oIZJ CITY 0 TOWN 0 VilLAGE
AND R 'd C't
SPECIFY apl I y
D. STREET ADDRESS 4190 Skyline Ranch Court ZIP 57701
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? I!f YES 0 NO
3. A. AGE ~1 3B. DATE OF BIRTH 1 n / 15 / 1 ~55
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE IS;:J;:JC':s-RlJssp.1I
(OPTIONAL - SEE REVERSE) 341-48 7949
D. SOCIAL SECURITY NUMBER -
12. RESIDENCEA. H;:Jmnshire, UK B. Hamoshire
(STATE) (COu;:m;)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
~~~CIFY Petersfield
D. STREET ADDRESS 5 Church Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/'13 A952
DAY YEAR
13. A. AGE 54
3B. DATE OF BIRTH
11
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Physician
B. TYPE OF INDUSTRY OR BUSINESS Medical
5. PLACE OF BIRTH Tulsa, Oklahoma
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Charles Daniel Russell Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dorothy Jane Hummel
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Psychoanalyst
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH ChicaQo. Illinois
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Roger David Isaacs
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Joyce Rayna Wexler
B. COUNlTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) r:5 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 02/ 07 / 2006 . C, DATE LAST MARRIAGE ENDED? 04 / 26 / 2002
MONTH DAY YEAR MONTIi.,I DAY' ',~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? [j YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONITH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
02/07/2006 Rapid City, South Dakota r$ 0 1ST 04/26/2002 London, England ~
o 0 2ND 0
o 0 3RD 0
o 4TH
f that the information I provided is true
1ST
2ND
3RD
4TH
I duly swear/affinn, depose and say, that h
as to my right to enter into the marnag tate
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
USEC~RE NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFOdi;'t.tE ~./li /1. A , ~
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 by New York Domestic
Relations Law ~11 to perfonn 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) Joh C. Masterson
{SEAL SIGNATURE ~ DATE 09/11/2007 TIME MONTH YEAR MONTH
'- -.J MAI~ Mrd8i~ h Rd, Wappingers Falls, NY 12590 AM 09 12 2007 11 10 2007
-v- 12:18PM
STREET ClTYrrOWN STATE ZIP
~~~R~~RT~~J IO~O~~~N:,zEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 B"6VIL
DATE AND AT THE TIME AND / .
PLACE INDICATED. fr::p ~ P 9 0 OTHER, SPECIFY
DATE
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYj)l(TC~P~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY po t/ 6 II J/eeIJ/;;
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)