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DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thom_.~~~ JAb
MIDDLE CU R SU E
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONLY)
I
COUNTY DutchesS
CITYfTOWN Wappinger
1368
72
.J
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
AI_Leigh a.~ANAME
1. A. 1'Ull. NAME
11. A. 1'Ull. NAME
FIRST
ARST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE BraRReR - (;.-au
(OPTlONAL - SEE REVERSE) ~
D. SOCIAl SECURl1Y NUMBER 119-7?-1.d3?
12. RESIDENCEA. ~. Vane B. ~
C. CHECK ONE 0 CITY 0 r;1rYNN 0 VILlAGE
~~ J:Mlhlrill
D. STREET ADDRESS 17~ Old ~ftI"'" 9
C. SURNAME AFTER MARRIAGE
(OPTlONAL - SEE REVERSE) 1 n...t ~D ~D..t
D. SOCIAl SECURITY NUMBER -~
2. RESIDEHCEA. ~Vnrlr B. (C~~II
C. CHECK ONE 0 CITY 0 'lIlt-OWN 0 VILlAGE
~~CIFY F"tshkill
D. STREET ADDRESS 175 Old Route 9
ZIP 12524
E. IS RESiDENCE WITHIN UMrTS OF CITY OR INCORPORATED V1ll.AGE? 0 YES 0.-0
~/DR1 /~g
12524
E. IS RESIDENCE WITHIN UMrTS OF CITY OR INCORPORATED VILLAGE? 0 YES D..eo
3. A. AGE~ 38. DATE OF BIRTH MO~ DAy11 / YEAR197
ZIP
13. A. AGE 25
14. EMPLOYMENT
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Admiristndiv- __At
B. TYPE OF INDUSTRY OR BUSINESS PAR C.
15. PLACE.OF BIRTH (C~~ltrtr Vodc
16. FATHER
A. NAME stephAn Paul BraQr:aen
B. COUNTRY OF BIRTH U ~ A
17. MOTHER
A. MAIDEN NAME AArbAf'A Ann 11,.ntt
B. COUNTRY OF BIRTH U S f4.
18. NUMBER OF THIS MARRIAGE 1
w
a
A. USUAl OCCUPATION Plumber
B. TYPE OF INDUSTRY OR BUSINESS Mr. RoatAr
5. PLACE OF BIRTH Sh8ron. Canneetiout
(CfTY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Thorn_ G"", Jr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAlDEN NAME K8thertne ~o
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
DEATH
o
DEATH
o
(2) 0 DEATH
(2) 0 DEATH
B. HOW 010 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) (ClTYICOUNTY, STATEICOUNTRY. IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
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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) (CfTYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
1ST
2ND
3RD
o
o
o
o
o
o
DATE
e bride and groom named above by any person authorized by New York Domestic
ate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
nly for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS'
TIME
MONTH
YEAR
O9:08M
PM
06
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1 IFf' CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B.COUNTY])UitHF5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [jo"'f"OWN OF 0 VILlAGE OF
SPECIFY ~ I '5 H K J LI-
NAME (PRINT)
SIGNATURE~
DOH-98 (0712005)
NAME (PRINT)
SIGNATURE~