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11.
N
COUNiY Dutchess
CITYfTOWN Wappinger
~~~:fFi 1368 .
~5~~J~R 113
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Donald Wilson Smith. III
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Alison Christine Bennett
MIDDLE CURRENT SURNAME
.J
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Smith
(OPTIONAL - SEE REVERSE) 067-54-7579
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r:! TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 34B Alpine Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
11 /06 ~973
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 113-60 5268
D. SOCIAL SECURITY NUMBER -
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!l' TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 15C Alpine Drive
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
08 / 18 / 1975
MONTH OAY YEAR
13. A. AGE 32
3. A. AGE 30
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Automotive Technician
B. TYPE OF INDUSTRY OR BUSINESS Healey Bros. Chev.
5. PLACEOFBIRTH Carmel, New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Donald Wilson Smith, Jr.
B. COUNTRY OF BIRTH USA
14. EMPLOYMENT
A. USUAL OCCUPATION Hairdresser
B. TYPE OF INDUSTRY OR BUSINESS Madison Avenue
15. PLACE OF BIRTH Carmel, New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Edson Thomas Bennett III
. B. COUNTRY OF BIRTH U S A
17. MOTHER
A. MAIDEN NAME Gail Fairhurst
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 2
7. MOTHER
A. MAIDEN NAME Terry S. Stevens
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1VOBCE CIVIL ANN~LMENT DEyr DIVfRCE CIVIL AN~LMENT D~H
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID lAST MARRIAGE END? (3) c:r'D1VOR15 (3) DQ3ULMENT 626~ DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 6 / / 2
MONTH DAY YEAR MONTH,/ DAY' " - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUNTY. STATElCOUNTRY. IF NOT USA) ~LF SPO~SE 1 ST (oID5~'2Cfd~ cWmer.wewcror'k' IF NOT USA) ~: SPO~SE
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
knowledge and belief that the information I provided is true t no legal impediment exists
~
1ST
2ND
3RD
4TH
I duly swear/affirm, Clep'ose an
as to my right to enter into m
21. SIGNATURE OF GROOM~
Y 1 that to the best of
nage sta e.
UJ_
USE CU NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 08/02/2006
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 e. 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-"-.. 24. TOWN OR CITYJC~RK C M t 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) onn . as erson
{SEAL} SIGNATURE ~ .
MAI~ t\9R
'-v-I
YEAR
TIME
MONTH
YEAR
MONTH
DATE 08/02/200
a Is, NY 12590
01 2006
AM
03:34pM
08
03
2006
10
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER. SPECIFY
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~ ~'S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFYiift-&r HS tfK,11...V
1 J6,.CIVIL
NAME (PRINT)
SIGNATURE~
OOH-98 (0312006)
NAME (PRI
SIGNATURE