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048 fj 10 N .. >= Z !Ii i .... . ~ ~ I ~ ~ en en w cr: o o <( >- u. (j W 0- en ~:I:Z i?~g W ~~~ .- ....wz <C gJdiii (J ~~g u:: z- - n~t5 I- itoen a: 0....>- W w~~ (J b~"' Z:::i~ 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 0- N 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 W t- ;0 en 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 .- :> <C c w - "u. Suo ~<C z ;: o to >- t- o 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 o o o cr: W III ::; => Z o z <( t- W W 0: t- en 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 w en z w (J ::i 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 ~