111
~
....
>-
z
.,;
f
i
f
J
<(
i
t
I
I
I
s:
~
W
II:
o
o
<(
>-
u.
li
w
0-
W
~:i:z
~~~ W
:i!~~ ....
>-wz <(
~d~ 0
~~g ii:
z-
~~~ i=
ttow a:
0>->- W
w~(!i 0
b~~
Z::i~
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard William Gardner
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY Dutchess
C1Tvrrowf WaPJingef
"I)ISTRICT 368
NUMBER
REGISTER 111
NUMBER
~
L 0 SUPPLEMENTAL FilE
FROM THE BRIDE
Jennifer Lynn ZUbradt
FULL NAME
FIRST MIDDLE
CURRENT SURNAME
11. A.
FIRST
MIDDLE
CURRENT SURNAME
0-
N
B. BIRTH NAME (MAIDEN NAME), ~:~
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)122-66-5484
D. SOCIAL SE~ITY N'BEI1c utch
12. RESIDENCE A. f'JN 0 B. D ess
(STATE)" (COUNTY)
C. CHECK otJi >__.JlL~'.:U 0 TOWN 0 VILLAGE
AND VViI~r~
SPECIFY 5 WI<tMxJd Drive AJL 8d '2590
D. STREET ADDRESS ZIP 01
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORAWILLAGE9t' 0 1~ NO
13. A. AGE 13.B. DATE OF BIRTH --
MONTH DAY YEAR
14. EMPLOYMENT FO o. D_..... R
,"ana ~ "Ice epo
A. USUAL OCCUPATION H. V. F. C. U.
B. TYPE OF IND~lB'l.!ilB~~ ....-.... k
NOIV1 .8 r~ TOI'
15. PLACE OF BIRTH ·
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Timothy David Zubracl:
A. NAME USA
B. COUNTRY OF BIRTH
w
>-
<(
>-
w
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)1;l;:J t)6 11~
D SOCIAL SEC=U~ER
2. RESIDENCE A. ork B. DutCheSS
(STATE)" (COUNTY)
C CHECK ONi. >__1:1: CITY 0 TOWN 0 VILLAGE
AND VVilpplnger
SPECIFY 5 WlctMJod DrIve AJi. ad
D. STREET ADDRESS ZIP
E. IS RE~ENCE WITHiN LIMITS OF CITY OR INCORPORATED 1~GE? 3Cf
3. A. AGE 4 3B. DATE OF BIRTH /
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Landscaping
B TYPE OF INDUf.iN~S~ V=poyed
5. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER Richard Lawrence Gardner
A. NAME
B. COUNTRY OF BIRTH USA
7. MOTHER She I -II I gI
A. MAIDEN NAME ran &.G;N e n es
B. COUNTRY OF BIRTH U $, A
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V'fjCE CIVIL ANtfLMENT
DE(jH
12590
01
Y/~9Wo
YEAR
....
:>
<(
c
w -
"u.
::'iu.
~<(
z
s:
o
to
>-
>-
C3
17. MOTHER Cheryl Unda Rubino
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DltrRCE CIVIL A"OULMENT
DroTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
C. DATE LAST MARRIAGE ENDED?
YEAR
II:
W
lD
::;
=>
z
o
z
<(
>-
w
W
II:
>-
<J)
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the InformaliDn I provided IS true and that I declare that no legal impediment exists
as to my right to enter Into the marriage state, ~ - pf. ~
21. SIGNATURE OF GROOM ~ r 22 SIGNATURE OF BRIDE ~ ~ CURREN~ N~ ~~
23 SUBSCRIBEO AND SWORN TO BEFORE ME ~ ~uurL\AI'"
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York St e of the bride and groom named above by any person authorized by New York Domestic
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 to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CIJdh t:'Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
w
C/)
Z
W
(J
::::i
r-'--.
{ SEAL }
'-v-'
YEAR
SIGNATURE
M
ZIP
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY]:;uizt{~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF j;I~WN OF 0 VILLAGE OF
SPECIFY 'f1-S-1- f6htrU-
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
s'
PM /C
TITLE6;.9~c ilc- ~~(;.J
I () / 2 ~ /'2 ec>s
,
1/'/' /2-$'3
31.
SIGNATURE ~'