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056 l1. N ~ .... >- Z .; ! I I I It Ii ~ J: r/) r/) W a: o o < ~ (3 W l1. r/) ~~~ W ~~~ ~ li;~~ (,) :>(.lW ~~g u:: ~~~ t: [Or/) W Of-> wm~ (,) b~"' Z:J~ STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM COUNTY Dutchess CITYfTOWN Wappinger ~~~:~c~ 1368 ~~~~~~R 56 1 . A. FULL NAME ChpPber Anhert Cnrt'te5 FI MIDDLE CURRENT SURNAME B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) 1 "'" 7o.~ D. SDCIALSECURITYNUMBER _~-~ 2. RESIDENCE A. NwXork B. Q~ C. CHECK ONE 0 CITY tItJ TOWN 0 VILLAGE AND .AI- . SPECIFY VVMA!1'lglW D. STREET ADDRESS 110 ShAr'wDad Forest ZIP 12590 IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO M~ /~ /j!82 8 r/) E. 3. A. AGE 23 4. EMPLOYMENT A. USUAL OCCUPATION 88nkAr B. TYPE OF INDUSTRY OR BUSINESS CHlhAnlc 5. PLACE OF BIRTH ~J~~~oY~ 6. FATHER A. NAME RobNt A l"..ordM. B. COUNTRY OF BIRTH USA 3B. DATE OF BIRTH l- S; <C C wU:: "u.. ~<C I 13 7. MOTHER A. MAIDEN NAME NAn~ PAtrlcla Ucl<MnA B. COUNTRY OF BIRTH lJ S A 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 (3) 0 ANNULMENT (2) 0 DEATH C. DATE LAST MARRIAGE ENDED? / / MONlH 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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE I STATE FILE NlJIIIreR (THIS SPACE FOR STA TE USE ONL Y) 11. A. L 0 SUPPLEMENTAL FILE FROM THE BRIDE FULL NAME Ci"~ Marie SUsan AR MIDDLE ~ CURRENT SURNAME B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT C. SURNAME AFTER MARRIAGE C"~ (OPTIONAL - SEE REVERSE) 132 ~ 3563 D. SOCIAL SECURITY NUMBER -, ,,- 12. RESIDENCE A. New V nrIc B. n. ..~ (STATE) (COUNTY) C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE AND We . SPECIFY ppnger D. STREET ADDRESS 11 0 SherWQgd Forest ZIP 12590 o YES~ NO 'lM2 YEAR E. IS RESIDENCE WITHIN UMITS OF CrTY OR INCORPORATED VIlLAGE? 13. A. AGE 23 3B. DATE OF BIRTH 06 AA MONTH DAY 14. EMPLOYMENT A. USUAL OCCUPATION SuhRttbJte Teacher B. TYPE OF INDUSTRY OR BUSINESS \Napp. ctrI. Sch. DIst. 15. PLACEOFBlRTHBMoan. NewVork (CITY, STATE / COUNTRy IF NOT USA) 16. FATHER A. NAME Paul . inIIP.ph EllitIon, Jr B. COUNTRY OF B1RTHU S A 17. MOTHER A. MAIDEN NAME Marianne PatrIcia McCarthy B. COUNTRY OF B1RTHU S A 18. NUMBER OF THIS MARRIAGE 1 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DEATH o B... HOW OlD LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH C. DATE LAST MARRIAGE ENDED? / / MONTH DAY YEAR 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) (CITYICOlJNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE URE OF BRIDE" o o o 1ST 2ND 3RD 4TH I duly swear/affirm, depose and say, as to my right to enter into the o 1ST o 2ND o 3RD o 4TH d belief that the information I provided is true a: w lD :. ::> z o z < ... w w ~ en 21. SIGNATURE OF GROOM" USE CU ENE 23. SUBSCRIBED AND SWORN TO/AFFIRMED BE ORE ME SIGNATURE OF TOWN OR CITY CLERK ~ This license authorizes the marriage in New York State of authorized by New York Domestic Relations Law 1111 to perform marriage ceremonies within New York tate. 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS W CJ) z W o ::i ~ { SEAL } "-v-I NAME (PRINT) TIME MONTH YEAR MONTH YEAR DATE 051'22/2006 Falls NY 12590 CITY OWN STATE 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY TIME MO. DAY YEAR OI't1"REUGIOUS STREET I CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF THE PER- SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND PLACE INDICATED. ZIP AM 05 02:14PM 21 2006 23 2006 07 28. PLACE WHERE MARRIAGE OCCURRED oc. 9 0 OTHER, SPECIFY 1 0 CIVIL A. STATE NEW YORK B. COUNTY ;;:u~~ C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF C!'fOWN OF SPECIFY (2.~ 29. OFFICIANT NAME (PRINT) o VILLAGE OF ZIP ". ."."" ro~ NAME (PRINT) lJV'i; $ ~r ~~ SIGNATURE~ ~