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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1. A. FULL NAME ~ric ~R
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
COUNTY Dt dcbess
CITYITOWN Wappinger
~~J~~c~ 1368
~~~~l~R 19
L D SUPPLEMENTAL FILE
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11. A.
FROM THE BRIDE
FULL NAME AnlIP Lee l1JR~es
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Mathis
c. s~S~(M.~~~~t~~e~~s~lIn
D. SDCIALSECURITYNUMBER 046-74--0648
12. RESIDENCEA.~A~ B.~
C. CHECK ONE 0 CITY " TOWN 0 VILLAGE
AND 'Ai- .
SPECIFY YHlPP'ngf'lI'
D. STREET ADDREss52 n.hftrNrl1-ll1l R~d AP 2 ZIP 125M
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE"'II: 13.B. DATE OF BIRTH n7 /.0 ...tan
I/I.~ -,roNTH '1t DAY I~R
14. EMPLOYMENT
A. USUAL OCCUPATION Cehier
B. TYPE OF INDUSTRY OR BUSINESS Pd~ l'~
15. PLACE OF BIRTH DftIWlhItaAnlllA NMAI Ynri(
~1F'~
16. FATHER
A. NAMEJame- TJvvnAll M~~
B. COUNTRY OF BIRTHlI S P.
17. MOTHER
A. MAIDEN NAME Shlryn Lee MeyeA
B. COUNTRY OF BIRTHtJ S A
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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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 095 68-6596
2. RESIDENCE A. N~T~OJIc B. ~I
C. CHECK ONE 0 CITY.jji! TOWN 0 VILLAGE
AND We .
SPECIFY ppnger
D STREET ADDRESS 52 ()sbornA HII Roed. ~ ~IP 125M
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES.tJ NO
3. A. AGE 35 3B. DATE OF BIRTH MQI / QIy /1;i1Q
4. EMPLOYMENT
A. USUAL OCCUPATION Night Manager
B. TYPE OF INDUSTRY OR BUSINESS Price CboppM'
5. PLACE OF BIRTH ~"mU~N~i\It
6. FATHER
A. NAME Emil Donald Wegman
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Edth Joen Mohan
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? n4 /?A /~
MONTH DAY YEAR MONTr m ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? rMYES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 04I26l2005 poughkeepsie, tJ~.JYOlX ~
2ND 0 0 2ND 0
3RD 0 0 3RD 0
~ 0 0 ~ 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and exists
as to my right to enter into the marria,9y s~.
21. SIGNATURE OF GROOM ~ '~~ . 22. SI ATURE OF BRIDE ~
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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
Relations Law ~11 to perform marriage ceremonies within
o II checked, this license is to
24. TOWN OR CITY CLERK
YEAR MONTH DAY
YEAR
DATE
I the bride and groom named above by any person authorized by New
York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL}
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NAME (PRINT)
TIME
MONTH
DATE CJ3l2OOf'V1R
AM
PM
03 21 2006 05 19 2006
ZIP
TA
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN:~CIfr~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
1~VIL
29. OFFICIANT
NAME (PRINT)
. ZIP
31. WITNESS TO CEREMONY
SPECIFY ~.-". ,-
i: A< rFi.s If j:i u..,
NAME (PRINT) J(
SIGNATURE~ ·
DOH.98 (11/98)
NAME (PRINT)
SIGNATURE ~
.
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