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1 A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
DOUGlas John ClimftOfl
:s 1 A 11= ~ILI= NUMtlER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTDutchess
CITYITOW~Vappiflger
DISTRICT ·
NUMBE~368
REGISTE
NUMBER 26
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
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11. A. FULL NAMElvnn ~nn MII~r.nlinn
:J FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE rannnn
(OPTIONAL - SEE REVER~b
D. SOCIAL SECURITY NUMBER 11_;~R167
12 RESIDENCEANe'!!fTXerk B.D~~~~~S
C. CHECK ONE DCITY ~ TOWN D VILLAGE
AND _litH .
SPEClfYVlfRpplnger
o STREET ADDRESs45 .~ Scarborouah Lane
ZIP 12590
DYES 'tJ NO
1Q61
YEAR
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 086-56-5067
B D~ss
VILLAGE
2. RESIDENCE ANewwAM~r1<:
C ~~6CK ONE D CITY.,LJ TOWN D
SPECIFY poughkeepsie
D. STREET ADDREss62 Lindbergh Place ZIP 126n~
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES..rJ NO
..86H /12..y /1~~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
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07
MONTH
13.B. DATE OF BIRTH
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A. USUAL OCCUPATION Toll Collecter
B TYPE OF INDUSTRY OR BUSINESS N V S Thruway
5 PLACE OF BIRTHp~~~~*\% York
6. FATHER
13. A. AGF44
14. EMPLOYMENT
A. USUAL OCCUPATIONl.lerical
B TYPE OF INDUSTRY OR BUSINESS Verizon Business
15. PLACE OF BIRTHtJlanhattan. New Vork
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEFrardc MII~r.nlinn
B COUNTRY OF BIRTflJ S A
DAY
3. A AGE46
4. EMPLOYMENT
3B DATE OF BIRTH
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A NAME Robert Johfl CanAen
B COUNTRY OF BIRTH U S ^
7. MOTHER
A. MAIDEN NAME Darbal'8 Ann Duncofl
B COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
17. MOTHER
A. MAIDEN NAME Barbara S~rRrdi
B. COUNTRY OF BIRTI't J ~ 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
DEATH
o
2 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) D ANNULMENT
C. DATE LAST MARRIAGE ENDED? ...-n~ / ?R
MONTH'"' Uft"I"'
D. ARE ANY FORMER SPOUSE(S) ALIVE? !;1YES D 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
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
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C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST 01/1:;:1992 Norwich, New Yert ~ D 1ST D D
2ND 01/20:2000 poughkeepsie, New Vert D D 2ND D D
3RD D D 3RD D D
4TH D D 4TH D D
I, being duly sworn, depose and ay, that to the bes of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right tD enter into the a riage
21. SIGNATURE OF GROOM ~ '
23.
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This license authorizes the marriage in New York State of e bride and groom named above by any person authorized
Relations Law 911 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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
by New York Domestic
~
{ SEAL }
'-v-'
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
AM
06:37PM
06
04 2006
04
06
2006
ZIP
AT
27. TYPE OF CEREMONY
oJ'! RELIGIOUS
9 D OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED f\ I J ,.
A. STATE NEW YORK B. COUNTY IJ!Ji!;I/M.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
1 CITY OF tf TO"';N ,9F D VILLAGE OF
SPECIFY (Q11 &II1:.~tJ5Jl,
5T
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1 D CIVIL
29. OFFICIANT
NAME (PRI
_0;:>
NAME (PRINT)
SIGNATURE ~