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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
DtM-d 1=9rt D1rst
I
STATE FI1.E NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutch-
CITYfTOWN Wappinger
~~~~ 1388
~~~~R 61
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME.JeI;Wp ~ B~
CURRENT SURNAME
11. A.
CURRENT SURNAME
l1.
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B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT t)avis
C. s~~~cM,~~~~~~~~s~~ "'-1
D. SOCIAL SECURITY NUMBER ~-~-
12. RESIDENCE A. Neff'A~odc B. ~r
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY w.ppi~ FallA
D. STREETADDRESs77 P9 T~ ZlP1~
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? <tJ YES 0 NO
13. A. AGE 42 3B. DATE OF BIRTH L ~AY ~
14. EMPLOYMENT
A. USUAL OCCUPATION Pym TedvHdlill1
B. TYPE OF INDUSTRY OR BUSINESS legion Flr~
15. PLACE OF BIRTH Falmouth. Maine
(CITY. STATE I COUNTRY IF NOT USA)
~
~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D. S~~~I1~,EENU:~RSE)207_36-9101
2. RESIOENCEA. NtrtXodc' B. ~f!iS
C. CHECK ONE 0 CITY 0 TOWN e VILLAGE
~C1FY Wappi~ FAk
D. STREET ADDRESS 77 Pegs; TAIT8ee ZIP 12590
E. IS RESIDENCE WITHIN UMlTS OF CITY OR INCORPORATED VILlAGE? !!! YES 0 NO
3. A. AGE61 3B.DATEOFBIRTH ".. /"Y) / 4QAJ;.
~
4. EMPLOYMENT
A. USUAL OCCUPATION {'..ahlp- ~i~ ('~mll"rflfinn
B. TYPE OF INDUSTRY OR BUSINESS ~iIIItrft ~
5. PLACEOFBlRTH~t~~~
6. FATHER
A. NAME st~ [)strP-c
B. COUNTRY OF BIATH USA
7. MOTHER
A. MAlDEN NAME ~nA p~
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
A. NAME RobeItNeel 0IMf.
B. COUNTIRY OF BIRm' $ ~
17. MOTHER
A. MAIDEN NAME Madan Louise Viles
B. COUNTIRY OF BlAT'" I S A
lB. NUMBER OF THIS MARRIAGE 2
16. FATHER
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE ~VtL ANNULMENT DEATH
., n 0 1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) r!!! DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATELASTMARRlAGEENDEO?n4 / ill /1QQ1 C. DATE LAST MARRIAGE ENDED? MONTH10 / M /1aaA
l!ONTH DAY ~ m ~
O. ARE ANY FORUEfl SPOUSE(S). AUIIE? ..i!vES 0 NO D. ARE ANY FORMER SPOUSE(S) AUVE? i!l'YES 0 NO
10. IF PREVIOUSLY DtVORCED OR ANNUllED, PROVIDE THE FOLLOWING INFORMATION 2D. IF PREVIOUSLY DIVORCED OR ANNUlLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUN'TY. STAlIEICOIJNTRY, IF NOT USA) SELF SPOUSE (MONTH. DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SelF SPOUSE
1ST 1omJ1984 HoIn.hllF.g, PA. 0 ~ 1ST 101'D811998 DN9'~e. NAwVork ~ 0
2ND 0411611991 Carmel, New York 0 ~ 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, dep.ose and ledge and belief that the infDnnation I provided is true and that I declare that no legal impedim nt exists
as to my right to enter into the
DEATH
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21. SIGNATURE OF GROOM ~
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CffY CLERC"- DATE
This license authorizes the marriage in New York State of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York ta. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this Hcense is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
YEAR
TIME
MONTH
YEAR
MONTH
NAME (PRINT)
SIGNATURE ..-
MAILING AQDRESS
09:44 AM 05
PM
27
2006
07
25 2006
ZIP
STATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYC--P",~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY ~1J!d Sr~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
STREET
3D. WITNESS TO CEREMONY
NAME (PRINT) .f) a/t? .A-,tJ n 7r-t' 4)
SlGNATURE"- .{J c.L.IA. A-,,(()~
DOH-98 (0712005)
SIGNATURE"-