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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Vi~Rt M. EalM.\, Jr.
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutche5S
CITYfTOWN Wappinger
~~~~:fFi 1368
~5~I~J~R 44
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A.
FUUL NAME MB~Coth&rin~on
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Carlon
C. SURNAME AFTER MARRIAGE ~8"8n
(OPTIONAL - SEE REVERS~ :!J
D. SDCIAL SECURITY NUMBER 112 11 9901
12. RESIDENCE A.N&lI'IfAV~rk B D~s
c. ~~CK ONE 0 CITY 0 TOWN I;jIo VILLAGE
SPEclFYWappinger-s Falls
D. STREET ADDREss12() Mark. Sir..., Suite 1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? .ItI YES ONO
13. A. AGES3 13.B. DATE OF BIRTH OINTH lSDAY ,9'S2AR
14. EMPLOYMENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SDCIAL SECURITY NUMBER 11 () <1 I] 6299
2. RESIDENCE A. N_'tolt B. D~ss
c. CHECK ONE 0 CITY 0 TOWN IiZI VILLAGE
AND W. r
SPECIFY applngers rails
D. STREET ADDRESS 120 Mance! street, Suite 1 ZIP 1259D
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
MPlH /1iBv / Wi
3. A. AGE61
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Highway Con3truetion Insp&ctor
B. TYPE OF INDUSTRY OR BUSINESS Boswell Engineering
15. PLACE OF BIRTHP~M~._~ YoFk
16. FATHER
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A. USUAL OCCUPATION Salel Exe~ulW8
B. TYPE OF INDUSTRY OR BUSINESS BoUini Fuel
5. PLACE OF BIRTH c;~s~RM;..NWuX~r:k
6. FATHER
A. NAMEFff.tAk Thomas Carlon
B. COUNTRY OF BIRTItl S A
17. MOTHER
A. MAIDEN NAME Rtdh Schmidt
B. COUNTRY OF BIRT~&rrnony
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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A. NAME Vincent Matthew EagaR
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Louise Elsie OF8haRl
B. COUNTRY OF BIRTH U $ A
8. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 9 (1
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MON"~3 / 13 / 1 ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? III 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
DEATH
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2 D 0
B. HOW DID LAST MARRIAGE END? (3)~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12 /?? / ?""3
MONTH 1l'j.'If ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? Ii!'! 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
1ST oJ/30/1gB7 Poughkeepsie, N Y
2ND 1212212003 Poughkeepsie, N Y
3RD
4TH
I, being duly sworn, depose and say, that to the best of my knDwle
as to my right to enter into the marri st te.
o ~ 1ST 0311311984 Poughkeepsi&, New York 0 .I;iiI
~ 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~711~ {}. 6 /I ~
SE CURRENT NAME .
.
DATE
21. SIGNATURE OF GROOM ~
by New York Domestic
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE05,q)3./2006
YEAR
MONTH
YEAR
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME
MONTH
2006
07
02 2006
04
, STA
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT-;J}tifCIlt-l&
C. LOCATION. OF CEREMONY
(CHECK ONE AN~PECIFY)
o CITY OF cVtOWN OF 0 VILLAGE OF
SPECIFY tf:,\L&-JI /::fJfL1'S it.
S
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)