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COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~~: 1368 .
~5~I:J~R 75
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rir:h;:!rrl Frir: r.ook
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
.-J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cas~~Ltmber SrTJ~tRENT SURNAME
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FiRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE r.ook
(OPTIONAL - SEE REVERSE) 0804
D. SOCIAL SECURITY NUMBER 133-68-
12. RESIDENCEA.NAW York B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Hyde Park
D. STREET ADDRESs4 Pond Road
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)058 70 2114
D. SOCIAL SECURITY NUMBER ___ - __- _ _ __
2. RESIDENCEA. NFW YORK B. nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ..tJ TOWN 0 VILLAGE
~~~CIFY Hyde Park
D. STREET ADDRESS 4 Pond Road ZIP 12601
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
O? / 1 n / 19RO
MONTH DAY YEAR
ZIP 12601
o YES'6 NO
1-980
YEAR
E. IS RESIDENCE WITHIN UMITSOF CITY OR INCORPORATED VILLAGE?
13. A. AGE 27 3B. DATE OF BIRTH 04 ~2
MONTH DAY
3. A. AGE ?7
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Tree Trimmer
B. TYPE OF INDUSTRY OR BUSINESS Tree Trimming
5. PLACE OF BIRTH Poughkeepsie. New York
(CITY. STATE' COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Day Care
15. PLACE OF BIRTHPOuqhkeepsie, New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
16. FATHER
A. NAME Keith Eugene Smith
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Nancy Ann Ciupek
B. COUNTRY OF BIRTHU S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
A. NAME Richard T. Cook
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Barbara A. Wetzelberqer
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~I!hM~FR~~~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
..
2D. 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
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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ge and belief that the information I provided is tru
o 0
o 0
o 0
o 0
t no legal impediment exists
22. SIGNATURE OF BRIDE ~
U
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This liCense authorizes the marriage in New the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies . in 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.
r-I-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) n C. M
{SEAL. SIGNATURE ~ DATE 07/25/2007 TIME MONTH YEAR MONTH
'- -.J MA~~GrOO~~ sh R ,Wappinger Falls, NY 12590 AM 07 26 2007 09 23 2007
-v- 04:17 PM
STREET CITYITOWN ;; STATE ZIP
~~R~~Ri~~J 'o~O~N~ZE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DA YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER. SPECIFY
YEAR
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~L1.IC.H-tJP
C. LOCATION OF CEREMONY
(CHe;pKONE AND SPECIFY)
Iifc:ITY OF n TOWN OF 0 VILLAGE OF
SPECIFY--.tfu4 ~S L ~
NAME {PRINT) ·
SIGNATURE~ ,.