125
COUNTY Dutche,s
CITYITOWN Wappinger
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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
S~d Glenn MG~ygh
I
(THIS SPACE FOR STATE USE ONLY)
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L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME AIi~I,lauren HMky
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE 'ftc Hugh
(OPTIONAL, SEE REVERSI!l'
D. SOCIAL SECURITY NUMBER 120 46 1788
12. RESIDENCE AN..-Ay..,r:k B. Dt:i~~s
C. CHECK ONE 0 CITY "TOWN 0 VILLAGE
AND
SPECIFY La Grange
D. STREET ADDRESF:38 Vfill ROfJd zIP12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES otJ NO
13.B. DATE OF BIRTH fKl ../.. .. ../..!:L
~NTH i!:-tt DAY . ge~R
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)
D. SOCIAL SECURITY NUMBER 072 64
2. RESIDENCEA. N.T~Or:k
C. CHECK ONE 0 CITY oilI TOWN
AND
SPECIFY La Grange
D. STREET ADDRESS 38 VfJil Roarf ZIP 1260~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES otJ NO
A /3tQy /1,Vj4
110B
B.~II
o VilLAGE
13. A. AGE31
14. EMPLOYMENT
3. A. AGE41
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Court Clerk
B. TYPE OF INDUSTRY OR BUSINESS City Of Pougbkeep9it'
15. PLACE OF BIRTHP~~q~~.s~ISe*F NOT USA)
16. FATHER
A. NAMEDaniel Allen Hubeeky
B. COUNTRY OF BIRTI-lI S A
17. MOTHER
A. MAIDEN NAME Sylvia Joan Spinapolice
B. COUNTRY OF BIRTtU 5 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
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A. USUAL OCCUPATION Deputy Building Inspector
B. TYPE OF INDUSTRY OR BUSINESS City ('Jf Res:"~o"
5. PLACE OF BIRTHP(gM~~f'~m YOIY
6. FATHER
A. NAME Jerome Lloyd Me Hugh
B. COUNTRY OF BIRTH II c.;; A
7. MOTHER
A. MAIDEN NAME Faye Y'JOnne Foley
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
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B. HOW DID LAST MARRIAGE END? (3)~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? n7 / 1A / "lyn02
,MONTH DAY ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? r!f YES 0 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
1ST 02l1912DD2Dutth~",Co"NewYort. 0
2ND 0
3RD 0
4TH
I, being duly sworn, depose and S , at to
as to my right to enter into the riage s
21. SIGNATURE OF GROOM"
09f?817nns
by New York Domestic
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
1ST
2ND
3RD
o 0
o 0
o 0
o 0
legal impediment exists
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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 Sta of the 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,
o 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
{ } NAME (PRINT) .I()~~
SEAL SIGNATURE ~ !JIlin l:f, 'fA:~ DATE 09118{1005
'-v-I M~~.INMfd~I;1t.iftlr WAppinnp-; FAII~ NY 17~An
STRE~ . CI'i'rr'l'"OWN -r . STAtE ZIP
~~~R~~Ri~~~ 10~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS l'f(CIVll
DATE AND AT THE TIME AND ~ """
PLACE INDICATED. PM _ 0;; 9 0 OTHER, SPECIFY
. ..-. Fe (~,tf.t:
~~~:~~~~~ TITLE c ,t'l ~ It J~,-
DATE /O/IC/O-r
,
11
21 2005
YEAR
MONTH
YEAR
TIME
MONTH
AM
PM 09
29
2005
6:
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~aL<~
lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF trfTOWN ~F 0 VIL,LAGE OF
rtC;Hl< (t...1-
SPECIFY
SIGNATURE ~
MAILING ADD~SS
3<; S" t f\- f'" ~ r.,.
STREET
30. WITNESS TO CEREMONY
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.
1 AlI3/) r::,
STATE
ZIP
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NAME (PRINT) ~ C , ~ ~
SIGNATURE~ ~