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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
"'Ill' Keith P4.t~
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 05t24l2OO6
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of authorized by New York Domestic
Relations Law ~11 to perfonn marriage ceremonies within New York . THIS UCENSE 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE 05124/2006
Falls NY 12590
STATE
'0. TYPE OF CEREMONY
o 0 REUGIOUS
9 0 OlliER, SPECIFY
couNTY DUtchess
CITYrrOWN WaPP"08r
~~~:~ 1~
~5~~~R fig
1 . A. FULL NAME
CURRENT SURNAME
"-
N
B. BIRlH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) IV!' ~
D. SOCIAL SECURITY NUMBER nR?-~
2. RESIDENCE A. NwlQl:k B. ~esl
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND n... uooha.--i
SPECIFY r-YlI IV' ._~....-p.
D. STREET ADDRESS go P8rInAInM Boulevard ZIP 12803
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIUAGE? 0 YES ~ NO
3. A. AGE 58 38. OATEOFBIRTH~
4. EMPLOYMENT
A. USUAL OCCUPATION HP'IW.Y Fl1'lipniM1t Opmdnr
B. TYPE OF INDUSTRY OR BUSINESS fIJ8w Vork' Tllmn
5. PLACE OF BIRTH Pfrl-....H NMAI VtM'Ic
(CITY, STATE / rouNTRY IF NOT USA)
6. FATHER
A. NAME Albeit Dou~_ Purdy
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME C8tbedne G8IIlo
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 2
~
rn
....
~
C
wU:::
Clu..
~c:(
~
~
E
5
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEAlli
1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 08 / R1 / ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ~O
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMAllON
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
o
~
{ SEAL }
'-.t-'
NAME (PRINT)
SIGNATURE ~
MAILING ADpRESS
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AN~
PLACE INDICATED..
.'f!'"
29. OFFICIAr-f(io
NAME (PRINT)
I
STATE FlU: NU....""
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME KAthlNm Fran~ lJIn;en
ARST MIDDlE CURRENT SURNAME
B. B1RlH NAME (MAIDEN NAME), IF DIFFERENT Fd7gjhl'v\M
C. SURNAME AFTER MARRIAGE I A~Pllrt\I
(OPTIONAL' SEE REVERSEj~.. "~1666
D. SOCIAl SECURITY NUMBER ~--
12. RESIDENCE A.""" V nrIr B. nllt~
~ATE) (couNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~FY PolGhkeepsie
D. STREET ADDRESS30 Perkwood Boulevard
.-J
ZIP 12603
o YES of! NO
'Uf51
YEAR
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED V1UAGE?
13. A. AGE 54 3B. DATE OF BIRTH 08 AD
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPA1l0N AMhdart M8~
B. TYPE OF INDUSTRY OR BUSINESS M & T Bank
15. PLACE OF BIRTH Fort Warth. Texas
(CITY, STATE / COUNTRY IF NOT USA)
16.FAlliER
A. NAME (')avid Ricl1ard Fd7.gjibbDnR
B. COUNTRY OF BIRTHU S A
17. MOlliER
A. MAIDEN NAME RobMta louise VAmon
B. COUNTRY OF BIRTHU S A
18. NUMBER OF llilS MARRIAGE 3
o
o
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST .fMRRIAGE ENDED? Q2 / 02 /2004
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE lliE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST 11/29/1978 San Diego. California ~
2ND 02JD2I2004 pouahkeeDBie. New York ~
DEATH
o
3RD
o
o
o 0
o 0
legal impediment exists
llME
MONTH
YEAR
MON11i
YEAR
ZIP
AM
03:12PM 05
23 2008
25
2008
07
1~ CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY1J\J-T ;;"""fl.S~
C. LOCA1l0N OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF '81. TOWN OF 0 VILLAGE OF
SPECIFY ~ o...~t>'f\~~r