032
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M::lrk M ~t::lr::lr.Fl
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN WappinQer
~~~~:f~ 1368 '
~~~I~~~R 32
1. A. FULL NAME
FIRST
1--
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
11.
N
B. BIRTH NAME, IF DIFFERENT Mill!::
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 045-76-3003
2. RESIDENCE A NFlW Y nrk B. I1l1tr.hFl~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 37D Surrey Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
. 3. A. AGE 29 3B. DATE OF BIRTH 01 / 14 / 197R
MONTH DAY YEAR
Lo
~
4. EMPLOYMENT
A. USUAL OCCUPATION FIFlr.trir.i::ln
B. TYPE OF INDUSTRY OR BUSINESS Alom Electric
5. PLACE OF BIRTH Hartford, Connecticut
(CITY, STATE / COUNTRY IF NOT USA).
6. FATHER
A. NAME l1::lvirl FlIgFlnFl Mill~ ~r
B. COUNTRY OF BIRTH USA
SUPPLEMENTAL FILE
FROM THE BRIDE
Annmarie B Thiers
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE St::lr::lr.Fl
(OPTIONAL - SEE REVERSE) 133 64 5839
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY !!"l TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 37D Surrey Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tl)NO
05 /12 AgeO
MONTH DAY YEAR
13. A. AGE ?fi
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Medical Assistant
B. TYPE OF INDUSTRY OR BUSINESS S. D. Eye Care
15. PLACE OF BIRTH Hartford. Connecticut
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William Gene Thiers
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Kathleen Patricia Bosworth
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
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7. MOTHER
A. MAIDEN NAME Pauline Mary Dell' AQuilla
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 0 0
2ND 0 0 0 0
3RD 0 0 0 0
0 0
I -impediment exists
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
USE C RRE NA
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New Yo 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.
t-'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) J C. Mas erson
TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 05/04/2007
MAILING ADDRESS AM
'-v-I 20 Middl appinaer Falls. NY 12590 02:58PM 05
STREET CITYIT"5WN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME O. A YEAR 0 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND 6
PLACE INDICATED. ; rJf) 9 0 OTHER, SPECIFY
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
MONTH
DAY
YEAR
05
2007
07
03 2007
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou~uT'CJff.!
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
D CITY OF 0 TOWN OF ~LLAGE <;. JI.
SPECIFY w~ ",J,Srt.& ~