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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COUNTYDlftr.hp.~~
CITYfTOWN Wflppingp.r
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~G~~J~R31
1. A. FULL NAME
J. ~aymor:ld t.aatthew WAI~h
R T MIDDLE CURRENT SURNAME
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTE R MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 494-38-9174
2 RESIDENCE A. NE1WA.;t; ode B. ~~~
C. CHECK ONE D CITY ~ TOWN D VILLAGE
ANO UII .
SPECIFY napplngp.r
D STREET ADDRESS 1 ~67 Route 376 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES "tJ NO
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3. A. AGE33
4. EMPLOYMENT
A. USUAL OCCUPATION IlnerY'plnyp.ri
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH T 9Wntn ~AnAdA
(I ,STATEltOUNTRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
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A. NAME James Wal$'h
B. COUNTRY OF BIRTH ~An8d8
7. MOTHER
A. MAIDEN NAME Sheila Colcough
B. COUNTRY OF BIRTH ~AnAdA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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DEATH
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B. HOW DID LAST MARRIAGE END?
(3) D DIVORCE
(3) D ANNULMENT
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(2) D DEATH
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
:, I A I t:. t-ILt: NUMtst:.H
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
11. A. FULL NAME Charlotte Mary Straley
FIRST MIDDLE
B BIRTH NAME IMAIDEN NAME), IF DIFFERENT Straley
C. SURNAME AFTER MARRIAGE Walsh
(OPTIONAL - SEE REVERSE)119-72 2350
D. SOCIAL SECURITY NUMBER - - ----
12. RESIDENCE ANew York B Dutchess
iSr ATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
AND W .
SPECIFY applnaer
D. STREET ADDRESS 1267 Route 376
CURRENT SURNAME
ZIP 12590
DYES '6 NO
1.972
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE33 13.B. DATE OF BIRTH n9 n
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Cashier
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTH Pouahkeepsie. New York
(CITY~TATElCOUNTRY IF NOT USA)
16. FATHER
A. NAME Charles Mitchell Stralev
B. COUNTRY OF BIRTJ..I S A
17. MOTHER
A. MAIDEN NAME Regina Eleanor Secor
B. COUNTRY OF BIRTJ..I S A
lB. 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 DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) D ANNULMENT
/ /
(2) D DEATH
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa , that to the b
as to my right to enter into the marr ge state.
21. SIGNATURE OF GROOM ~
D 1ST
D 2ND
D 3RD
D 4TH
and belief that the information I provided is tr e a
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23. SUBSCRIBED AND SWORN TO BEFO E ME
SIGNATURE OF TOWN OR CITY CLE K ~
This license authorizes the marriage in New York State of t e 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.
D 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
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{ SEAL }
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NAME (PRINT)
tQ;J;;J-no
USE CURRENT NAME
DATE 04119/2006
by New York DDmestic
TIME
MONTH
YEAR
MONTH
YEAR
DATE 04/19/2006
09:47 AM 04
PM
18 2006
20
2006
06
ZIP
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o D RELIGIOUS
9 D OTHER, SPECIFY
~ CIVIL
29. OFFICIANT
NAME (PRINT)
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Dt4~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
SPECIFY
-e......
SIGNATURE ~