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COUNTY Dutchess
CITYfTOWN Waopinaer
~~~:~c: 1368 -
~~~~J~R 166
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FrArlA~i~D~E .Jo~eph ~~R~~rK[dR~~E
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
Lo
1. A. FUll. NAME
11. A. FUll. NAME
SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Anne Thomas
MIDDLE CURRENT SURNAME
..J
FIRST
0..
N
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Becker
(OPTIONAL - SEE REVERSE) 148 60 2379
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r:Y TOWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREET ADDRESS 198 Old Ketchamtown Roa~IP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
03 /17 /1975
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 131-66-9395
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NAW York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY lY' TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 198 Old Ketchamtown RoaQp 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rf NO
04 / 21 / 1968
MONTH DAY YEAR
3. A. AGE ~R
13. A. AGE 31
3B. DATE OF BIRTH
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Security
B. TYPE OF INDUSTRY OR BUSINESS Saks Fifth Avenue
5. PLACE OF BIRTH. Pouahkeeosie. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Frederick Joseph Becker. Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Pamela Hazel Secchia
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Marketinq
B. TYPE OF INDUSTRY OR BUSINESS Armstrong Shaw Assoc.
15. PLACE OF BIRTH Plainfield, New Jersey
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Gordon Thomas
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mina Tindall
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) []"l;,VORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 08/ 03 /
MONTH ~ DAY
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. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 08/03/2004 Dutchess Co., New York 0 if 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, dep'0S6 and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into theclJJar ge state.
21. SIGNATURE OF GRooM'- . SIGNATURE OF BRIDE~
u~C #
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 by New York Domestic
W Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
en 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W } NAME (PRINT) John C. Masterson .
o { / 1/2 0 TIME MONTH YEAR MONTH
::i SEAL SIGNATURE ~ DATE 1 0 1 0
I....- -J MAIL~5~cfm appinger Falls, NY 12590 AM 10 12 2006 12 10 2006
-v- 06:4&>M
STREET ClTYrrOWN STATE ZIP
~~iR~~R~~J ~~~~N~:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M . AY YEAR 0 IB"'RELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
2004
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
...- YEAR
o 0
o 0
o 0
o 0
impediment exists
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY f' uT N It/IA
29. OFFICIANT
NAME (PRINT)
TITLE ~ E"Ve(lEN))
1"/2-~/6'
N
STATE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [!(TOWN OF 0 VILLAGE OF
SPECIFY G-r1-(<..(LlSO/J IN. ~
SIGNATURE ~
MAILING ADORES
'"
STREET
30. WITNESS TO CEREMONY
DATE
NAME (PRINT)
SIGNATURE~
nnl-l_QR (MI?MII\
NAME (PRINT)
SIGNATURE~