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COUNTY Dutchess
CITYfTOWN WappinQer
~~~:kc: 1368 '
~~~I~~R 9
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Don~lrl I I p.arv
MIDDLE CURm;NT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
Lo
1. A. FULL NAME
11. A. FULL NAME
SUPPLEMENTAL FILE
FROM THE BRIDE
A~ Johanna VOriilt
MI LE CUR NT SURNAME
FIRST
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 053-56-7785
D. SOCIAL SECURITY NUMBER __
2. RESIDENCE A. Np.w York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cY TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 2717 West Main Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? r:::J"'YES 0 NO
3. A. AGE ~n 3B. DATE OF BiRTH 1 ? / 17 / 197
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Leary
(OPTIONAL - SEE REVERSE) 092 72 9265
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cYTOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 2717 West Main Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? d'" YES 0 NO
13. A. AGE 35 3B. DATE OF BIRTH 01 / 22 /1972
MONTH DAY YEAR
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Cashier
B. TYPE OF INDUSTRY OR BUSINESS Smokes 4 Less
15. PLACE OF BIRTH Yonkers. New York
(CITY, STATE J COUNTRY IF NOT USA)
16. FATHER
A. NAME Walter Bridgewater
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Elizabeth Vogt
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
A. USUAL OCCUPATION Allto Mp.ch~nic
B. TYPE OF INDUSTRY OR BUSINESS The Brake Shop
5. PLACE OF BIRTH Town Of Cortlandt
(CITY, STATE J COUNTRY IF NOT USA)
6. FATHER
A. NAME Frlg~r .JoSp.rh I P.~ry
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Shirley A See
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 DEAJH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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
to
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
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
w
en
z
w
(,)
::i
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 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 and that I declare that no legal impediment exists
as to my right to enter into the marnage state. rv+-
21. SIGNATURE OF GROOM ~ D. U~E CURRENT ~ ~~CU~~~E
23. ~~~~~~DO~~~~OJ': ci~A~r~:E~ BEFORE ME DATE 02/08/2007
This license authorizes the marriage in New York State of the brld and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. T 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.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
02
NAME (PRINT)
TIME
MONTH
YEAR
DATE 02/08/200
r Falls NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS 1 ~L
9 0 OTHER, SPECIFY
09: 1 ~M
PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK B.cOUNTY-'01..1~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF &;;WN OF 0 VILLAGE OF
SPECI~f I /I it' 0{
29. OFFICIANT
NAME (PRINT)
I " l.-
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)