102
+
OW
o>S
L{')",
N
......
>-
Z ....
~CI) :;:
Ul - c:(
::lea c
gLL -
~CI)~LL.
~....~LL.
~Q)~c:(
Qe:~
~'-g
!2ro5
~~
w
Cl
SQ)
lEe:
;!ro
u....J
Oe:
I!!'-
"'" ~
o
u::--
~a..
w
0('1')
ll!N
w .
i ~
2
~
Z
Q
~
Iii
w
~
Ul
Ul
w
a:
Q
~
~
o
w
...
Ul
w
en
z
w
0
::::J
+
iE~Z w
t_O
;ti= ....
a: ",;5 c:(
t;~~ 0
~Ow
::'Cl5 u::
!z~Ul i=
S~~
Q!2 It
ttocn W
0"'> 0
W!Jj1!i
...ffil()
~g~
1. A. FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST BerU~in Arth1lr cAmEQsuRNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368 .
~~~~~R 1 02
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ip::mim}DLt'::Itri~i::l r.&~M~ SURNAME
~
11. A. FUll NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 086-66-0fi4Q
2. RESIDENCE A. N\SrATE) B. qM~E''S'S
C. CHECK ONE 0 CITY oLJ TOWN 0 VILLAGE
AND W .
SPECIFY ::IpprngAr
D. STREET ADDRESS 143 Myers Corners Road: ZIP 12590
E. is RESIDENCE WI1HIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
3. A. AGE25 3B. DATE OF BIRTH MO~ / gAt / Uit3?
4. EMPLOYMENT
A. USUAL OCCUPATION nrivArlW::IrAhnll~A
B. TYPE OF INDUSTRY OR BUSINESS John Deere Landscaping
5. PLACE OF BIRTH Pouahkeensie New York
(CITY, ~ATE I collNTiiy IF NOT USA)
6. FATHER
A. NAME Rnhprt AllAn Imm
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Phyllis Suzanne Stratton
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. ~~~~l?~~R~R~/(,&T8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE 1m m
(OPTIONAL - SEE REVERS~)
D. SOCIAL SECURITY NUMBER 076-72-6249
12. RESIDENCEANY B.nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W '
SPECIFY applnger
D. STREETADDRESS143 Myers Corners Road:
ZlP12590
o YES~ NO
;(q81
YEAR
E. IS RESIDENCE WI1HIN LIMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AGE ?fi 3B. DATE OF BIRTH Ofi ;(j'Q
MONTH DAY
14. EMPLOYMENT
A.' USUAL OCCUPATION Finance
B. TYPE OF INDUSTRY OR BUSINESS Car Dealershio
15. PLACE OF BIRTH Bronx. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard William Cohen
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Patricia Elsie Lent
B. COUNTRY OF BIRTJ.! 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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DiVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEAJH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
., ~ - YEAR
(3) 0 ANNULMENT
/ /
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
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~ '10.~IPPREVIO[JStYDIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, deP.OSe and say, that to the best of my knowledge and belief that the Information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the mamage state. I ~ . ~
21. SIGNATURE OF GROOM~ US 22. SIGNATURE OF BRIDE~ 7~J~~NAMft
23 ~:::~~~Do~t!fo~Oo~ci~A~r~:E~ BEFORE ME DATE 08/29/2007
This license authorizes the marriage in New i'k State of the bride and groom named above by any person authorized by New Yoi'k Domestic
Relations Law ~11 to perform marriage ceremonies within New Yoi'k State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the purpose of a second or subsequent ceremon .
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J n C. Mas erson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
MAIl.I~G~IDR.fi$S AM 08 30 2007 10 28 2007
"-v-I LU IVIICall 05:19 PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURR~ .
A. STATE NEW YORK B. COUNTY ~(
,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
,
o CITY OF~OWN OF 0 VILLAGE OF
SPECIFY (.0 Pf f 'J ~ P f
NAME (PRINT)
SIGNATURE~
DOH.9B (03/2006)
A .. ~M (VI..
a., c.---L
NAME (PRI
SIGNATURE~