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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jonathan George Peterson
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~: 1368 .
~G~~J~R 98
1. A. FULL NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 591 97 8409
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. St. Maarten B.
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r!f TOWN 0 VILLAGE
~~~CIFY Beacon Hill
D. STREET ADDRESS 8 Hibiscus Lane
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tf NO
3. A AGE 25 3B. DATE OF BIRTH 01 / 20 / 1981
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BUSINESS Airport Aviation Company
5. PLACE OF BIRTH Philipsburg, St. Maarten
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME George M. Peterson
B. COUNTRY OF BIRTH Saba
7. MOTHER
A. MAIDEN NAME Winnifred A. Hassell
B. COUNTRY OF BIRTH Aruba
8. 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
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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Fallon M. Powers
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Powers-Peterson
(OPTIONAL. SEE REVERSE) 121-66-9375
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY c1 TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 5 Diddell Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES t1' NO
13 A. AGE 23 3B. DATE OF BIRTH 03 /15 /1'983
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS Marketing
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, ST ATE I COUNTRY IF NOT USA)
16. FATHER
A NAME Stephen G. Powers
B. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Carmen L. Colon
B. COUNTRY OF BIRTH Puerto RICO
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~ULMENT
DEtJ'H
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES
DAY
ONO
~
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
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and s
as to my right to enter into th
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
at the best of my knowledge and belief that the information I provided is tru
tate.
o
o
o
o
ent exists
USE cu ENT NAME
I ED BEFORE ME II.- .-I-tAL
RK~ ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 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 CITYICl,t:RKC M t 25 A SOLEMNIZATION PERIOD BEGINS
vonn . as erson . .
NAME (PRINT)
21. SIGNATURE OF GRO
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{ SEAL }
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22. SIGNATURE OF B
# ~ - .Jd-C" 0( ~
E~
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
SIGNATURE ~
MAI'm tmEl
07/14/200
DATE
appinger Falls, NY 12590
AM
01 :39pM
07
15
2006
09
12 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.
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
1~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou~1C.JifJ'aI
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY W~n.6 "i1"Y. ~
29. OFFICIANT
NAME (PRINT)
ZIP
" W,""'"" OE~'MONY " ~
NAME (PRINT) E\\~ \.-- W ~
SIGNATURE~ ~ - D --.... ~ Q.~.1