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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
N.mpafn I Hn~~~EOrsuRNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~.:~c: 1368 .
~5~1~~R 94
1 . A. FUll. NAME
FIRST
Q.
N
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mic~@~lr .Julia MctR~PisURNAME
-1
11. A. FUll. NAME
FIRST
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Hnffm::ln
(OPTIONAL' SEE REVERSE) 088-70-6761 (OPTIONAL. SEE REVERSE) 130 68 9368
D. SOCIAL SECURITY NUMBER ___ __ ___ _ D. SOCIAL SECURITY NUMBER _ - -
2. RESIDENCE A. NY B. nlltr:hA~~ 12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE C. CHECK ONE 0 CITY cY TOWN 0 VILLAGE
AND P hk ' AND P hk .
SPECIFY Ollg AApSIA SPECIFY oug eepsle
D. STREET ADDRESS 8 Stanley Street ZIP 12603 D. STREET ADDRESS 8 Stanley Street ZIP 12603
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r! NO
3. A. AGE 29 3B. DATE OF BiRTH n 1 / 19 / 1 Q7R 13. A. AGE ?6 38. DATE OF BIRTH 08 /14 /i 981
MONi'H DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
w
A. USUAL OCCUPATION FnginAAr
B. TYPE OF INDUSTRY OR BUSINESS Nxp Semi Conductors
5. PLACEOFBIRTH Binahamton. New York
(CITY, S'l"ATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Willi::lm .John Hoffman
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Margaret Ann Broton
B. COUNTRY OF BIRTH, USA
8. NUMBER OF THIS MARF,lIAGE 1
9. ~~~~~~JlR~FR~~~gus MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. Et.\PLOYMENT
A. USUAL OCCUPATION Financial Representative
B. TYPE OF INDUSTRY OR BUSINESS American General
15. PLACE OF BIRTH Poughkeeosie. NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Wayne John Mc Avoy
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Linda Florence Dickson
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
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) (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) (CIlYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. -.- YEAR
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
Y knowledge and belief that the Infonnation I provided is t
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CIlY CLERK ~ DATE
This license authorizes the marriage in New York State of authorized by New York Domestic
Relations Law ~11to perfonn marriage ceremonies within New York te. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this iicense is to be 'used onl se of a second or subse uent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jo C. Maste s
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 08/16/200
"- -.J MAI~O~dme in er Falls, NY 12590 AM 08 17 2007 10 15 2007
-v- 12:2q,M
STREET CITYITOWN STATE ZIP
~~~R~~Ri':J IO~O'#.~N~EE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TI E DAY YEAR 0 gRELlGIOUS
~~~E ~glt,.~~E TIME AND '- ! 30 AM t :J.~ 01-" 9 0 OTHER, SPECIFY
~~J>n~~~ , I.( ; I feY MO Ca.f4 (t'( /7 TITLE Fr;. -tf, if
SIGNATURE~ 1.1. N~~ ~ DATE! I ;z.. r--I 0 =l-
MAILING ADDRE~S D J S>. ,_ _ , J J \I
III u..tlf)./ VlLlff.y f\.{).. (O,;~ h ta:.etS1t- IV 7 fJ./g "3
STREET CITYfTOWN STATE ZIP
31. WITNESS TO CEREMONY
Ii
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
o
o
o
RE OF BRIDE ~
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A STATE NEW YORK B. COUNTY DtLtd-.<<s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 'ilfTOWN OF 0 VILLAGE OF
SPECIFY .pou..~ S; (....-
NAME (PRINT)
SIGNATURE~