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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, l.olCENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
BI}'M1 MamA ~
COUNTY Dutchess
CITYITOWN Wappinger
~~J~~CRT 1368
~5~~J~R 5
1. A. FUll NAME
CURRENT SURNAME
a.
N"
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 128 sa 2904
2. RESIDENCE A. ~J~cx:Ic B. ~
C. CHECK ONE D CITY ~ TOWN D VILLAGE
AND We .
SPECIFY PPlngef
D STREET ADDRESS 705 CbeIsee Ce:I ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? DYES 'Iti NO
3. A. AGE2& 3B. DATE OF BIRTH a /2;;ly / ~
4. EMPLOYMENT
A. USUAL OCCUPATION Insurance AqUlter
B. TYPE OF INDUSTRY OR BUSINESS Progressive Insurance
5. PLACE OF BIRTH~~.!i~Y~)
6. FATHER
.A. NAME Leonard Lundy
8. COUNTRY OF BIRTH IJ S A
7. MOTHER
A. MAIDEN NAME Teresa MaRe Y/8mke
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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(2) D DEATH
8. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
MONTH DAY YEAR
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FUll NAME H.... Eliz8~JomISt
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I · 'A~I
(OPTIONAL. SEE REVER~ WI
D. SOCIAL SECURITY NUMBER 124...7~ ~~76
12. RESIDENCE A.N.A~ B. ~m-
C. CHECK ONE D CITY r, TOWN D VILLAGE
AND We .
SPECIFY PPlngef
D. STREET ADDREss705 Chels. Cay ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? D YES'Iti NO
QJNTH 09DAy 1rf1~R
13. A. AGE27
14. EMPLOYMENT
A. USUAL OCCUPATION Floral Designer
B. TYPE OF INDUSTRY OR BUSINESS Rosemary's RorIst
15. PLACE OF BIRTH~~~F~r:t,cg
16. FATHER
13.B. DATE OF BIRTH
A. NAMEEdwin Albeit Forrest
B. COUNTRY OF BIRTftl S A
17. MOTHER
A. MAIDEN NAME CynthIa Ann Rleh8fdsen
B. COUNTRY OF BIRTf\J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) D DEATH
8. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION!
(~6'JfH~b2~C:~ER) (CITY, STA-r~gD~~~~~?F NOT USA) A~tc~S;p~~~~ t
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I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information 1 provided is true and that 1 declare that no
as to my right to enter i rriage state. .
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FORE ME
CLERK ~
This license aut zes the marriage in New York State of
1 to perform marriage ceremonies within New
D If checked, this license is to be
24. TOWN OR CITY CLERK
DATE 01126t2OO6
e bride and groom named above by any person authorized by New York Domestic
rk State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
ed only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME
MONTH
YEAR MONTH
YEAR
AM
PM 01
27 2008 03 27 2006 .
28. PLACE WHERE MARRIAGE OCCURREDR
A. STATE NEW YORK B. COUNTY ~
SIGNATURE ~