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COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~c: 1368 '
~5~~~~R 160
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Andrew Budd Bostwick
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rachelle Elizabeth Haddix
MIDDLE CURRENT SURNAME
-.J
1 , A. FULL NAME
11, A. FULL NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bostwick
(OPTIONAL - SEE REVERSE) 304-98-7807
0, SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY D" TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 26B Winthrop Court ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
07 /02 /1983
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 124-64-5345
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cY TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 26B Winthrop Court
12590
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D'" NO
3. A, AGE 27 3B. DATE OF BiRTH 04 / 25 / 197
MONTH DAY YEAR'
13. A. AGE 23
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Farmer
B. TYPE OF INDUSTRY OR BUSINESS Agriculture
15, PLACE OF BIRTH Munster, Indiana
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Edward Allen Haddix
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Susan Marie Hough
B. COUNTRY OF BIRTH USA
lB. 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 Sales
B. TYPE OF INDUSTRY OR BUSINESS Janitorial Distribution
5. PLACE OF BIRTH PouQhkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME William Carl Bostwick
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy Forwalt Budd
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
1ST 0 0 1ST . 0
2ND 0 0 2ND 0
3RD 0 0 3RD 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
as to my right to enter into the mamage state.
21. SIGNATURE OF GROOM~ h 22. SIG TURE OF BRIDE~ ~
USE CUR ENT
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of t authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York te. 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.
r-I'-.. 24. TOWN OR CITY PLIiRK C 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn . Masterson
{SEAL SIGNATURE ~ (j.ejO.~~ DATE 10/03/200 YEAR MONTH
'-v-' MAILI~AflJjMffi~sh Rcrwappinger Falls, NY 12590 2006 12 02 2006
STREET CITYITOWN STATE ZIP
~~iR~~R~~~ IO~O!#t~N~ZEE~ 26. SOLlEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIM M , YEAR 0 0 RELIGIOUS 1 ~IL
DATE AND AT THE TIME AND -::!:C>AM
PLACE INDICATED. M 9 0 OTHER, SPECIFY
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY \...\..l sW
-.....