131
0-
N
+
>-
z
W
rtJ
W
lXl
Cl
-'
::>
o
:I:
rtJ
Z
o
~
rtJ
a
w
a:
w
~
it
a:
<
::;
u.
o
w
!;(
()
u:
~
w
()
w
a:
w
~
rtJ
rtJ
W
a:
Cl
Cl
<
~
13
w
0-
rtJ
+
~~z
2-0
w~l=
a: ",;5
~ffi~
id~
ClO
>-zrtJ
z-
~~~
[om
0>->-
wllli3
bffi'"
Z~~
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~:~~ 1368 .
~~~I:~~R 1 31
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Cr~QDlfich~el R~U~~a~URNAME
I
STATE FilE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melanie Ann Welsh
MIDDLE CURRENT SURNAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 064 66 7850
D. SOCIAL SECURITY NUMBER --
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN r!!l' VilLAGE
~~~CIFY Wappingers Falls
o STREET ADDRESS 14 Stuart Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? rf YES 0 NO
3. A. AGE 27 3B. DATE OF BIRTH 10 / 03 / 1978
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Roberts
(OPTIONAL - SEE REVERSE) 120 70 4296
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ['I( VilLAGE
~~~CIFY Wappinqers Falls
D. STREET ADDRESS 14 Stuart Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
12 /26 ,;1'979
MONTH DAY YEAR
13. A. AGE 26
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION IT Consultant
B. TYPE OF INDUSTRY OR BUSINESS Duality Inc.
5. PLACE OF BIRTH Pouqhkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Albert Phillip Roberts
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Beverly Ann Furnari
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 Operations ManaQer
B. TYPE OF INDUS;RY OR BUSINESS Gold's Gym
15. PLACE OF BIRTH Poughkeepsie. New York
(CITY, STAre / COUNTRY IF NOT USA)
16. FATHER
A. NAME James Michael Welsh
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Eileen Ann Bentley
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
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
/ /
(2) 0 DEATH
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
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
w
en
z
w
o
::i
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 and say, that to the best 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 rnag~state. ~ 1 . 1.1 ^ L 0
21. SIGNATURE OF GROOM ~ rI/ - 22. SIGNATURE OF BRIDE ~ _ P _11.ArJ/\ g () tt:!. ~
USE CU . US];'OURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 08/23/2006
SIGNATURE OF'TOWN!OR CITY CLERK" DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perlorm 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 CITYJC RK C M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) 0 . as
{SEAL. SIGNATURE" DATE 08/23/200 YEAR MONTH
MAI~WfI~fi . Wappinger Falls, NY 12590 2006 10 22 2006
'-v--' STREET . CITYITOWN
~~~R~~Rir~~ IO~O~~~N:,z:~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND AM
PLACE INDICATED. 51[; '30 M \ 0 '2..0 0<.0
29. OFFICIANT HON. JAMES D~! ~GONES
NAME (PRINT)
YEAR
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYDvt(.."~
1")i. CIVIL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF'i;l TOWN OF 0 VILLAGE OF
SPECIFY fO'\l-3~k~~.s,~
31. WITNESS T
NAME (PRINT)
SIGNATURE"