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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
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(THIS SPACE FOR STA TE USE ONL Y)
Dutchess
COUNTY Wappinger
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NUMBER
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
Ann M~rreO&~~IBRIDE
11. A. FULL NAME
FIRST MIReaton
B. BIRTH NAME (MAIDEN NAME), K~ppT
C SURNAME AFTER MARRIAGE
. (OPTIONAL - SEE REVERSElua5-4E)-4515
D SOCIAL SE~'8fIe ~uffolK
12. RESIDENCE A. (STATE)'; B. (COUNTY)
C. ~~5CK Ollip 0 CITY 0 TOWN 0 VILLAGE
SPECIFY e Cinque Court 11105
D. STREET ADDRESS ZIP .,
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORAlflILLAGE?m 0 ~ NO
13. A. AGE 13.B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
14. EMPLOYMENT Bookkeeper
A. USUAL OCCUPATION Weldbeunts
B. TYPE OF INDlSR't..QlWJS"'i'ss._ . 'k
'..nl~rl5, I'<<'W 1 gr
15. PLACE OF BIRTH
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER Paul WIson Heaton
A. NAME USA
B. COUNTRY OF BIRTH
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
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B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~
(OPTIONAL - SEE REVERSE~'
D. SOCIAL SE<N~ Dutchel55
2. RESIDENCE A. . (STATE) " B. (COUNTY)
C. ~~5CK ONHydEfPBHc: 0 TOWN 0 VILLAGE
SPECIFY 7 Andree CotIrt
D. STREET ADDRESS
12601
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YEAR
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E. IS RE!!CE WITHIN LIMITS OF CITY OR INCORPORATE~GE? 140
3. A. AGE 3B. DATE OF BIRTH /
MONTH DAY
4. EMPLOYMENT Grounds Keeper
A. USUAL OCCUPATION Wapp. ca. Sch. Dist.
B. TYPE OF INDLeLlilr~e t' _. ...01........
rUUW'l~ . 'IV... , "
5. PLACE OF BIRTH
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER Walter Vincent Knapp, Sr,
A. NAME USA
B. COUNTRY OF BIRTH
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Ulllan Julia Evans
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 2
1B. NUMBER OF THIS MARRIAGE
17. MOTHER
7. MOTHER lois Jean Jaycox
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 2
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV'rCE CIVIL A1)ULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A'O'ULMENT
DlSTH
DEQTH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVO,O (3) ~ULMENT2()O~ DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIV'lft / ~ 1NNULM/'~ DEATH
C. DATE LAST MARRIAGE ENDED? MJ / DAY / YEAR C. DATE LAST MARRIAGE ENDED? MON1llfI' - DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATIONi
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM i
'tOr26?2OOfpoa~RlWVtH1c S~F SPOUSE dfJlf~1tWHafJi'Pi~ulQNf'W) SELF SPO~E
1ST '0 0 1ST ' 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
UH 0 0 UH 0 0
I, being duly sworn, depose and say, th t to the best of my knowledge and belief that the information I provided' impediment exists
as to my right to enter into the ma iag ta
21. SIGNATURE OF GROOM ~
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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 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 0 be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CI 'tkMasterson 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by New York Domestic
~
{ } NAME (PRINT) .
SEAL ~~ " '.
'-.,;-I
YEAR
04
04 2006
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY iAAch!S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF "VILLAGE OF
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~