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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST R ~fM1LE ~t;:m I\A n~E~ SURNAME
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
atto~he best of m knowledge and belief that the information I provided Is true and that I declare that no Ie
~~ ,
22, SIGNATURE OF BRIDE ~
USE CU USE CURRENT NAME
23. SUBSCRIBED AND SWORN T IRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yo State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies w in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pu se of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo
TIME MONTH YEAR MONTH
SEAL SIGNATURE~ DATE 08/14/200
'-v-I MAI~~aecffi in er Falls, NY 12590 09:41AM 08
STREET ClTYrrOWN STATE ZIP PM
~~~R~:RTl'~~ IO~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY 1..........CIVIL
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 0 RELIGIOUS aJ
~tl6E ~~gIC~~~E TIME AND d' AM 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYrrOWN Wappinger
~~~~c; 1368 .
~5~~~~R 92
1. A. FULL NAME
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) ,
D. SOCIALSECURITYNUMBER 103-76-2961
2. RESIDENCE A. NY B. nllt~hA!::!::
(iT ATE) 'l650N'1'Yi
C. CHECK ONE 0 CITY 0 TOWN Iiii!I' VILLAGE
~~CIFY W~rpingAr~ F;:)II~
D. STREET ADDRESS 1 Brick Row ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE ;n 3B. DATE OF BIRTH 06 / ?A. / 1 QR~
MONTH DAY YEAR
I
STATE FILE NUMaER
(THIS SPACE FOR STA TE USE ONL Y)
I
4. EMPLOYMENT
A. USUAL OCCUPATION Mp.r:h~nir.
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH Cortlandt, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME R~mon Frlwin Mor~IA~
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Rochelle Ann Stanton
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.IA~~ir:~ P;:)trid~ RhJ~rt
MIDDLE CURRENT SURNAME
-1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mnr~IAS
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 131-76-5813
12. RESIDENCE A. NY B. nlltr.hA!::~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 1 Brick Row ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r!1 YES 0 NO
13. A. AGE ?Q 3B. DATE OF BIRTH O~""5 A 978
MONTH DAY YEAR
14. E~PLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS DCC
15. PLACE OF BIRTH Pouahkeepsie. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Neil Arnold Stuart
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Maureen Ann O'Neill
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
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 AGAINSTWHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say
as to my right to enter into the m.a
21. SIGNATURE OF GROOM~
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'- YEAR
o
o
o
DATE
YEAR
15
2007
10
13 2007
28. PLACE WHERE MARRIAGE OCCURR~ . t
A. STATE NEW YORK B. COUNTY ~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY \/\ . ^'-' 09 or-
~ J
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH.98 (0312006)
NAME (PRINT)
SIGNATURE~