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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~c~ 1368
~~~I~~~R 179
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Charles Lindber~
MIDDLE CURRENT SU NAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dawn Marie Spencer
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
c.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Lindberq
(OPTIONAL. SEE REVERSE) 1 01-66-5286
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
D. :~:~~ A::~~~8~helsea Ridge Dnve ZIP
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 042-70-8879
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r!1 TOWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREET ADDRESS 24C Chelsea Ridge Drive ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 27 3B. DATE OF BIRTH 08 / 11
MONTH DAY
MONTH
12590
YES r1 NO
/1979
YEAR
12590
YES ti NO
/ 1979
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
11 /10
DAY
13. A. AGE 27
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Dutchess Cty. Soces
5. PLACE OF BIRTH New Milford, Connecticut
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Dale Michael Lindberq
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Deborah Joan Colacurcio
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Social Worker
B. TYPE OF INDUSTRY OR BUSINESS Orange Cty. A H R C
15. PLACE OF BIRTH Yonkers, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Charles Arthur Spencer
'B. COUNTRY OF BIRTH U S A
17. MOTHER
A. MAIDEN NAME Donna Maria Petrizzo
B. COUNTRY OF BIRTH U S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
D~TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(2) 0 DEAJH
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
..
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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 an1dr:a,y, that t 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/L~nage r\t\ .. . \ J J\ ^ S
21. SIGNATURE OF GROOM ~ 22 SI ATURE OF BRIDE ~ _~\ -V V \ - - ~ C1.A.
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE J1~E CU E USE CURRENT NA 12/01/2006
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York tate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be use only for the purpose of a second or subsequent ceremony.
,,-I'-.. 24. TOWN OR CITY Cl,ERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jonn C. Masterson
{SEAL SIGNATURE ~~ DATE 12/01/200 TIME MONTH YEAR MONTH
'-v-' MAI~Mf sh Rd, appinger Falls, NY 12590 02:16;~ 12 02 2006 01 30 2007
STREET CITYITOWN STATE ZIP
~~:R~~RT~~~ ~~O~~~N~Z:~ 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 LL
PLACE INDICATED. 7,:a> PM 90 OTHER, SPECIFY
~~~t~~~~~ ~.::J IJ,,(Wd> r, (&~ m" l~'" ~ ,,;-!tee
SIGNATURE~~~ fCP ~ DATE I. 13.2...1:::00
M~1[DDR~(2.~ ~c..~ U:trfU~~l(cn-. (O$'/L.
STREET CITYrrOWN STATE ZIP
30. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
YEAR
l~CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY p~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
C02..-lv\eJ-
SPECIFY
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
NAME (PRINT)
-----
SIGNATURE~