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COUNTY Dutchess
CITYffOWN Wapoinqer
~~~:~c; 1368 '
~~~~J~R 57
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
--1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sharon Anne Orton
FIRST MIDDLE CURRENT SURNAME
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT O'Rourke
C. SURNAME AFTER MARRIAGE Albertson
(OPTIONAL - SEE REVERSE) 115 52 0393
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cY TOWN 0 VILLAGE
~~CIFY Dover
D. STREET ADDRESS 479 Old Route 22 ZIP 12522
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r1 NO
10 /17 /1960
MONTH DAY YEAR
1 . A. FULL NAME
P~LJI Fsmond Albertson~ III
MIDDLE CURRENT URNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERE~
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 1 09-56-6028
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFY Dover
D. STREET ADDRESS 479 Old Route 22
ZIP 12522
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:! NO
04 / 29 / 195
MONTH DAY YEAR
13. A. AGE 46
3. A. AGE 48
3B. DATE OF BIRTH
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Administrator
B. TYPE OF INDUSTRY OR BUSINESS NYS DEC
15. PLACE OF BIRTH Hartford, Connecticut
(CITY, STATE I COUNTRY IF NOT USA)
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Electric Motor I nd ustrv
5. PLACE OF BIRTH Newburah. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME Michael William O'Rourke
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Rita Fortier
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
A. NAME Paul E. Albertson. Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mabel Ann Douahtv
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,IIAGE 2
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL A~ULMENT
1 0 0 1 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) D~IVDRCE (3) 0 ANNULMENT jg) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 02/ 18 / 1997 c. DATE LAST MARRIAGE ENDED? 05 / 31 / 2u06
D. ARE ANY FORMER SPOUSE(S) ALlV~r~ "fES 0 ~~ YEAR D. ARE ANY FORMER SPOUSE(S) ALlV~~NT~ES DD~~ . . - YEAR
..
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
(MONTH, DAY, YEAR) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEARl (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 02/18/1997 Goshen, New York D~ 0 1ST 05/31/2000 Poughkeep~ie, New YorK 0 r1
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH .; 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true ,no legal impediment exists
as to my right to enter into th ,map(' state. ,.-'
21. SIGNATURE OF GROOM~ ~ ~ 22. SIGNATURE OF BRIDE~
U
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in NewY State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform 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 urpose of a'secol)d or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J n C. Masterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
'- ~ MAJ~B~cfaT AM 06 21 2007 08 19 2007
-v- 04:5~M
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DEATH
o
06;20/2007
DATE
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 1>VTZ.#~4S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF .Qt'VILLAGE OF
SPECIFY /);tftvt-r N 6-
TITLE R.Q. ?I€:r~~ T
DATE C> " /J~fl, 7
PAw t"7,,vC- ;v,X' I).. J'1f
STATE
NAME (PRINT)
SIGNATURE~