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~31!;
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rene V. Foucaud
MIDDLE CURRENT SURNAME
FROM THE BRIDE
Rita M. Backer
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Mills
C. SURNAME AFTER MARRIAGE F 0 u ca u d
(OPTIONAL - SEE REVERSE) 133-64-1600
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY WappinQer
12590 D. STREET ADDRESS 14A Scarborough Lane ZIP 12590
YES ~ NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/ 1959 13. A. AGE 41 3B. DATE OF BIRTH 04 /20 A965
YEAR MONTH DAY YEAR
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New State f the bride and groom named above by any person authorized
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 purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) J hn C. Ma
TIME MONTH YEAR
SEAL SIGNATURE~ DATE 01/24/200
\.- .-J MAIy'N~ ~qr:>I'FlE~
-v- LU M aal ;WappinQer Falls, NY 12590
STREET CITYITOWN STATE ZIP
~~~R~:RT~~J IO~O~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0
COUNTY Dutchess
CITYITOWN Wappinger
~~J:~c: 1368 .
~~~~~~R 5
1 . A. FUll. NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 113 50 6343
D. SOCIAL SECURITY NUMBER --
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wapoinaer
STREET ADDRESS 12D ScarborouQh Lane
~
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4. EMPLOYMENT
A. USUAL OCCUPATION Retired
B. TYPE OF INDUSTRY OR BUSINESS Con-Ed
5. PLACE OF BIRTH Queens. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Rene W Foucaud
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gloria Pane
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MAR81AGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) d'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 06/ 04 / 2002 .
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
06/04/2002 PouQhkeepsie, New York d
DEATH
o
t:i
W
a:
Ii;
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and
as to my right to enter into th
21. SIGNATURE OF GROO
SIGNATURE ~
MAI",ADDRE
STREET
30. WITNESS TO C,EREMONY
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
~
11. A. FULL NAME
14. EMPLOYMENT
A. USUAL OCCUPATION Data Entry
B. TYPE OF INDUSTRY OR BUSINESS Publishing
15. PLACE OF BIRTH Yonkers, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Donald Hall Mills
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Anne Marie Chiaverini
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) dDIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 05 / 2001
MONT!:!."I DAY' . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? LIYES 0 NO
.-
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
09/05/2001 Carmel, New York r:f
DEATH
o
o
o
1ST
2ND
3RD
4TH
that the Information I provided is tnue
o
o
22. SIGNATURE OF BRIDE~
DATE
01/24/2007
by New York Domestic
MONTH
YEAR
01
25
2007
03
25 2007
28. PLACE WHERE MARRIAGE OCCU~ _
A. STATE NEW YORK B. COUNTY t( I C JIB
C. LOCATION OF CEREMONY
(CHECK ONE AN7ECIFY)
o CITY OF [!(TOWN OF 0 VILLAGE OF
SPECIFY IN ~, A..b-u2.,
.
r
NAME (PRINT)
SIGNATURE~ ·