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STATE OF NEW YORK
DEPARTMENT OF HEALTH
r
STAn: FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW 010 LAST MARRIAGE END? (3) ~ DIVORCE (3) D ANNULMENT (2) 0 DEAlll
C. DATE LAST MARRIAGE ENDED? 12 / 27 /2005
MONl1i. DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? n YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING lNFORMATION
DAlE OF DECREE PLACE lSSUED AGAINST WHOM
~TH, DAY, YEAR) (CITYIOClUNlY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST 12127f2005 Poughkeepsie. NY !j
2ND
3RD
4TH
I duly swear/affirm, depose and say. ltIat to the best of my
as to my right to enter into the~ma . .-;::
21. SIGNATURE OF GROOM. ~: .
USEC
23. SUBSCRIBED AND SWORN TO/AF ED BEFORE ME
SIGNATURE OF TOWN OR CITY RK~
This license authorizes the marriage in New Y State of the bride and groom named above by any person authorized
Relations Law 911 to perform maniageGeremonies within New York Stale. THIS UCENSE VAUD IN NEW YORK STATE ONLY.
o If checked, lhis license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINTJ3C. Masterson
{ SEAL. SIGNAnuRE~ e~~ DATE05I26l2OO6
"-v-' ~1t.B Rei, \N;"ppinger Falls. NY 12590 2:33
STREET CITYJrOWN STATE ZIP
~~:'~~R~~~IO~O~~~N~z::. 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMEDAIlOVE ON THE TIME MO. DAY YEAR 1 ~IL
DATE AND AT THE TIME AND fiJ'$'
PLACE INDICATED. -.
COUNTY Dutchess
CITYffOWN Wappinger
DISTRICT 1368
NUMBER
REGISTER 62
NUMBER
1. A. FULL NAME
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
steDhen F Bock
FIRST MIDDLE
CURRENT SURNAME
n.
N
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) nnD DD A105
D. ~LSECURITYNUM8ER U~
2. RESIDENCE A. New York B Dut:ch~c:.
(STATE) (COUNTY)
C. CHECK ONED CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADORESS 770 Old Route 9. Ad 2 ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIUAGE? D YES ~ NO
3. A. AGE29 3B.DATEOFBIRll-l nG /1., / 1Q7~
MONTH OAY vm----
w
B
(J)
4. EMPLOYMENT
A. USUAL OCCUPATION Driver
B. TYPE OF iNDUSTRY OR BUSINESS Rental
5. PLACE OF BIRTH Yonkers. NY
(CITY, STAlE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Stephen M. Bock
B. COUNTRY OF BlRll-l U S A
7. MOTHER
A. MAIDEN NAME Juclth A Aram
B. COUNTRY OF BIRTH USA
a. NUMBER OF THIS MARRIAGE 2
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29. OFFICIANT
NAME (PRINT)
S EET CITYff. WN
30. WITNESS T~REMONY ~
NAME (pRINT) ~"(l c€..f>r - b; a. N ()
SlGNATURE.h~ "'fl~
OOH-98 {07/2005)
Lo SUPPLEMENTAL FILE
FROM THE BRIDE
1 ettb'ne F Sa{SffIl
~
H. A. FUu'I!IAME
CURRENT SURNAME
B. BIRTH IIlAME {MAlDEN NAME), 'IF DIFFERENT
c. 5lf=~~~r:~RS~
D. SOCIAl. SECllRflY NUMBER 104-F\4..8860
12. RESIDENCE A.Ne;wAX,ork B. D~~E
C. CHECKONE D CITY Iil TOWN 0 VILLAGE
AND tAl- .
SPEClFY v_pp"~r
0. STREET ADDRESS 770 Old RoutfIJ 9, ~ 2 ZIP 12590
E. IS RESIDENCE WlTHINIJMITS OF CITY OR INCORPORATED Vli.AGE? 0 YES e NO
13. A. AGE 25 3B. DATE OF BIRTH L 110M _
14. EMPLOYMENT
A. USUAL OCCUPATION I lnemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH NfNI Yow !\IV
(CITY, STA'lE ~IF NOT USA)
16. FATHER
A NAME11nknawn
fl. COUNTRY OF BlRTtII S A
17. MOTtlER
A. MAIDEN NAME. lI,anits M Sargent
e. COUNTRV OF B1md I S A
18. NUMBER OFTHlSMARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
DEATH
o
Q
(2) 0 DEAlll
B. HOW OlD LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNUUolENT
/ /
YEAR
C. DATE LAST MARRIAGE ENDED?
MONlli OAV
O. 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, fJAV, VEAR) (ClTYICOUNlY, STATEICOUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
D
D
D
22. SIGNATURE OF BRID
TIME
YEAR
it
25 2006
28. PLACE WHERE MARRIAGE OCCURRED
STATE NEW YORK B. COUNTY- M~r 66
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY' J ~\ rr IJ- ~..p r-
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