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COUNTY Dutchess
CITYfTOWN Wappinqer
~~~:~c; 1368 '
~~~~J~R 173
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David Ja~ Idema
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
1. A. FULL NAME
11. A. FULL NAME
SUPPLEMENTAL FILE
FROM THE BRIDE
Heather 1. DePew
MIDDLE CURRENT SURNAME
~
Lo
FIRST
FIRST
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Idema
(OPTIONAL - SEE REVERSE) 121 72 3455
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cYTOWN 0 VilLAGE
AND W .
SPECIFY appmaer
D. STREET ADDRESS 145 Chelsea Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
09 / 21 /1978
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 081 58 8601
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cY TOWN 0 VilLAGE
AND W .
SPECIFY applnger
STRm ADDRESS 145 Chelsea Road
12590
ZIP
D.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 41 3B. DATE OF BiRTH 01 / 23
MONTH DAY
DYES dNO
/ 196
YEAR
13. A. AGE 28
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Newburah. New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Todd William DePew
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Bobbie Bell
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
A. USUAL OCCUPATION Driver
B. TYPE OF INDUSTRY OR BUSINESS Herring Sanitation
5. PLACE OF BIRTH Poughkeeosie. New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME David Idema
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Brown
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 03/ 24 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 \If:s 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
03/24/1993 Pouqhkeepsie, New York 0.... 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
t of my knowledge and belief that the infom1ation I provided is true and
. (3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
(2) 0 DEATH
1993 .
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) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
21. SIGNATURE OF GROOM~
1ST
2ND
3RD
4TH
I duly swear/affim1. dep.ose and sa
as to my right to enter into the m Iflge
W
en
z
W
o
::::i
USE CUR ENT
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of t
Relations Law ~11 to perfom1 marriage ceremonies within New York
o If checked. this license is to be used
r-"-. 24. TOWN OR CITY q:ER.~, .
{ } NAME (PRINT) "!'II
SEAL SIGNATURE ~t.' DATE 1 0/26/200
'-v-' MAIL~~~r ebu~h Rd, Wappinger Falls, NY 12590 11 :2a.M
STREET CITYITOWN STATE ZIP PM
~~R~~Ri~~J lo~O~~N~f~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 00 RELIGIOUS 1~ CIVIL
DATE AND AT THE TIME AND I -IJ AM ,....
PLACE INDICATED. 1: " 9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY _1A I~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF !i'TOWN OF 0 VILLAGE OF
SPECIFY PI a.,b/;c. Kif /
DATE
1 0/26/2006
by New York Domestic
TIME
MONTH
YEAR MONTH
YEAR
10. 27 2006 12 25 2006
SIGNATURE~
DoH-98 (0312006)
NAME (PRINT)
SIGNATURE~