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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c: 1368
~~~~~~R 1 51
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jeffre~ Thomas Wilder
MID LE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Amber Leah Grant
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
1 1. A. FULL NAME
FIRST
FIRST
0.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wilder
(OPTIONAL - SEE REVERSE) 085-72-9705
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 917 Dutchess Turnpike ZIP 12603 '
E. IS RESIDENCE WITHIN UMITS OF CllY OR INCORPORATED VILLAGE? 0 YES d' NO
13. A. AGE 20 3B. DATE OF BIRTH 02 /12 /f 986
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 664
D. SOCIAL SECURllY NUMBER 094 -7 8-4
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY!'!f TOWN 0 VILLAGE
~~~CIFY LaGranqe
D. STREET ADDRESS 2295 Route 82
12540
YES ~ NO
/ 1984
YEAR
ZIP
E. IS RESIDENCE WITHIN UMITS OF CllY OR INCORPORATED VILLAGE? 0
3. A. AGE 22 3B. DATE OF BIRTH 06 / 02
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Cable Installer
B. TYPE OF INDUSTRY OR BUSINESS Telecom Solutions
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Bradford Lee Wilder
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Myra Jean DeSha
B. COUNTRY OF BIRTH USA
8. 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 Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Sharon, Connecticut
(CITY, STATE / COUNTRY IF NOT USA)
\
16. FATHER
A. NAME Robert D. Grant
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Deborah L. Morgan
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
w
UJ
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::::i
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to he best of my knowledge and belief that the information I provided is true and t
as to my right to enter into the mama e......___..___._
22. SIGN1TURE OF BRIDE ~
USE C RENT NAME ~ \
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
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 CITYJCl,ERK C M t 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) onn . as erson
{SEAL } SIGNATURE ~ '
MAI~ WflB'tl
'-v-I
o
o
o
NAME - 09/13/2006
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
ZIP
11
12 2006
YEAR
DAY
YEAR
MONTH
DATE 09/13/200
appinger Falls, NY 12590
2006
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
Oft:
Ie
SPECIFY
NAME (PRINT)
SIGNATURE~