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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
Devi FBONlelTI::lE GROOM
n Dam Burger
Dutchess
COUNTY VVIiIpPll
CITYfTO\\l~ WVI
DISTRICT"
NUMBER 48
REGISTER
NUMBER
1. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSeQ70-62.64, 9
D SOCIALSE~'~
2. RESIDENCE A. B. DutcheSS
(STATE) ., (COUNTY)
C. CHECK OfllEj, .--lI <:.lm'. 0 TOWN 0 VILLAGE
AND VVIiIJ4.lInY"J
SPECIFY 17G Wdte G8te DrI
D. STREET ADDRESS YO
ZIP 12590
.,
Y/f9j~
YEAR
E. IS RF.lWtNCE WITHIN LIMITS OF CITY OR INCORPORATE~LAGE? 0
3. A. AG~~ 3B. DATE OF BIRTH ~
MONTH DAY
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4. EMPLOYMENT
A. USUAL OCCUPATION Manufacturing
B. TYPE OF INDg88dU.' B. M.
5. PLACE OF BIRTH ' Vork
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER NI A
A. NAME
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy Burger
B. COUNTRY OF BIRTH U 51 A
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'tjRCE CIVIL AtfULMENT
DftTH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH riA Y YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME NOOole A Thompson
FIRST MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME),~DlFFERENT
C. SURNAME AFTER MARRIAGE urger
(OPTIONAL - SEE REVERSEI144-B2-8970
D. SOCIAL S= 'fork Dutch
12. RESIDENCE A. B. ess
(STATE)'; (COUNTY)
C. CHECK ~ 0 CITY 0 TOWN 0 VilLAGE
~~~CIFY ppnger
D. STREET ADDRESs17G \M'fte Gate DrIve
Zlp1~
o YES "0 NO
1983
E. IS R~NCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~~ 13.B. DATE OF BIRTH 02 ~
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIO~rect care Aide
B. TYPE OF IN~~':!.SIt!fjstete or New YorK
15. PLACE OF BIRT pwn ns, NeW JerSey
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAMplenn Thompson
B: COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAM~ Redner
B. COUNTRY OF BIRTAJ S ~
18. NUMBER OF THIS MARRIAGE
YEAR
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
~ORCE CIVil AlrUlMENT
DQ^TH
B. HOW DID 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 ANNUlED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST 0 0 1ST
~ 0 0 ~
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is tr e
as to my right to enter into the' .
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi New York State. 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 'JBrihEe. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ~ ~
SEAL SIGNATURE ~ e. DATE05ID9I2OO6
'-.,-I ~1lMCI Rd, ppinger Falls, NY 12590
STREET CITY /TOWN STATE
~~~R~~Ri~~~ 10~O~~~N~EE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMEO ABOVE ON THE TIME MO. DAY YEAR o~ RELIGIOUS
DATE AND AT THE TIME AND .
PLACE INDICATED\\ ! ~:06 ~ J \ 0,," 90 OTHER, SPECIFY
29. OFFICIANT . 0 ,\ L' . \ B N,......L ".i..A ..... .. I
NAME(PRINT)~ r\eY,~:.J;~d('g_ . \ \urn <::' TITLE- l\.-h01s1er
~Z~"'"~' 1~~~ il~ ",,4, tl \~'t (" ,1i1V
STREET CITYfTOWN ST ZIP
30. WITNESS T C 31. WITNESS TO CEREMONY
NAME (PRINT) YL'i3 Eft-. I3
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DATE
by New York Domestic
TIME
YEAR
1:08
AM
PM
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVil
A. STATE NEW YORK B. COUNTY Df'o..n3e
c. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF :J VillAGE OF
SPECIFY oM ir.1c\\e~u:>n
SIGNATURE ~
