120
STATE FlLE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
I
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard Edward Jones. JR.
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfrOWN Wappinger
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SUPPLEMENTAL FILE
FROM THE BRIDE
Lisa Michele Wood
MIDDLE CURRENT SURNAME
11, A, FULL NAME
1 , A, FULL NAME
FIRST
FIRST
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Jones
(OPTIONAL. SEE REVERSE) 077-72-6669
0, SOCIAL SECURITY NUMBER
12, RESIDENCEA. New York B- Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY r!l' TOWN 0 VILLAGE
~~CIFY Poughkee~sie
0, STREET ADDRESS 120 Channingvllle Rd; Apt 6~ 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIUAGE? 0 YES ~ NO
07 /21 /1'980
MONTH DAY YEAR
0-
N
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 114-66-9002
0, SOCIAL SECURITY NUMBER
2. RESIDENCE A, New York B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Pouqhkeepsie
0, STREET ADDRESS 120 Channingville Rd; Apt~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE? 0
3. A, AGE 24 3B. DATE OF BiRTH 08 / 14
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Sheetmetal Mechanic
B. TYPE OF INDUSTRY OR BUSINESS HV AC
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
6, FATHER
A. NAME Richard Edward Jones
B. COUNTRY OF BIRTH USA
+
12590
YES '6 NO
/ 1981
YEAR
13, A, AGE 26
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Office Manager
B. TYPE OF INDUSTRY OR BUSINESS HV AC
15. PLACE OF BIRTH Beacon, New York
(CITY, STATE I COUNTRY IF NOT USA)
16, FATHER
A. NAME Milton Joseph Wood
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Michele Jean Di Castro
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI~fRCE CIVIL AN8ULMENT
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7. MOTHER
A. MAIDEN NAME Margaret Mary Kelley
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV<t)CE CIVIL ANcyLMENT
D~TH
DEtJH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- 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) (CfTYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(2) 0 DEATI1
(3) 0 ANNULMENT
/ /
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
hat I declare that no legal impediment exists
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
knowledge and belief that the information I provided is true an
G
USE CU
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yo 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 S"!'ATE ONLY.
o If checked, this license is to be used onl for the urpose of a second or subsequent ceremony.
24. TOWN OR crr" CI...ERKC M t 25 A SOLEMNIZATION PERIOD BEGINS
JOnn . as erson . .
NAME (PRINT)
22. SIGNATURE OF BRIDE ~
by New York Domestic
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{ SEAL }
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YEAR
MONTH
TIME
08/09/2006
ATE
appinger Falls, NY 12590
SIGNATURE ~
MAI~ MR!
08 2006
10
2006
10
AM 08
05:41 PM
ZIP
STATE
27. TYPE OF CEREMONY
o IX RELIGIOUS
9 0 OTHER, SPECIFY
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
+
10 CIVIL
A. STATE NEW YORK B. COUNTY Dutchess
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
a CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY Poughkeepsie, NY 12603
AM
3:30mdl
9-16-06
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TITLE Pastor
29. OFFICIANT~D iel B~Ward
NAME (PRINT) -.-~
SIGNATURE
MAILING AD RESS
St. John's Evangelical Lutheran
STREET CITYfrOWN
30. WITNESS TO CEREMONY
NAME (PRINT) Chr i
SIGNATURE~
hnl-l.QR {M.l?nM\
9-16-06
DATE
55 Wilbur Blvd. Pok,
STATE
NAME (PRINT)
SIGNATURE~