103
0-
N
~
o
to
('II
~
..l&
....
~
~
~
l,
I
I
Qj
~
~
CD'
~
1i
~
()
~
U)
U)
w
a:
o
o
<(
>-
U-
(3
W
0-
U)
~:i::i
~~g w
~~~ ~
>--wZ .....
~dro 0
~~g u::
z-
~~~ i=
tEoU) a:
0>-->- W
w~;3 0
b~U}
Z::i~
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c; 1368
~5~'iJ~R 103
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
~
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
FROM THE GROOM
Michael Arthur ThomDson
FIRST MIDDLE
FROM THE BRIDE
11. A FULL NAME Christie Ann narrow
FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
8 BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)120-72 9278
o SOCIAL SECURITY NUMBER -
2. RESIDENCE A New York B. Dutchess
(SWE) (COUNTY)
C. CHECK ONE LJ CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY ou~ eepsle
D STREET ADDRESS 54 Violet Avenue ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
04 /23 /1976
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Thomp!'l:nn
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 12(}..~fl-R6nn
12. RESIDENCE ANew York B. n. dr.hp.!'l:!'l:
(STATE) ~OUNT'i)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~ClFyPoughkeepsie
D. STREET ADDREss154 Violet Avenue zIP12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? -tJ YES 0 NO
13. A. AGE?Q 13.B. DATE OF BIRTH 11 .to ~ltlE;.
MONTH DAY 'I'EAR
14. EMPLOYMENT
A. USUAL OCCUPATIONReal Estate Processor
B TYPE OF INDUSTRY OR BUSINESsHudson Valley F C U
15. PLACE OF BIRT.,eouahkeeDsie. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMECharles Morton Darrow
B. COUNTRY OF BIRTtU S A
17. MOTHER
A. MAIDEN NAME Louise Ellen laffion
B COUNTRY OF BIRTU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
3. A. AGE29
3B. DATE OF BIRTH
w
!;(
>--
U)
4. EMPLOYMENT
A. USUAL OCCUPATION Salesman
B. TYPE OF INDUSTRY OR BUSINESS East Penn Manufacturing
5 PLACE OF BIRTHPoughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Gary Carroll Thompson
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Carol Grace Goodrich
B COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVirCE CIVIL AOULMENT
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
...
:>
<(
c
w -
<olL
:"ilL
~<(
z
~
o
to
~
U
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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, STATEJCOUNTRY, IF NOT USA) SELF SPOUSE
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, STATEJCOUNTRY, IF NOT USA) SELF SPOUSE
a:
w
"'
::;
=>
z
o
z
<(
>--
w
w
a:
>--
U)
15T 0 0 15T 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 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 that I declare th~no legal Impediment exists
as to my nght to enter Into the marnage state. C f'_ t\
21 SIGNATURE OF GROOM~ /1- ~~'J;;2 SIGNATURE OF BRIDE ~ L..Jl~.~' liJl..------
/ . USE CURREN ME
23. A I~~ DATEOB13112005
This license authorizes the marriage in New York State of t bride and groom named above by any person authorized by New York Domestic
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 CLTY CLE~ 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JO c:. Masterson
{ ~
SEAL SIGNATURE ~ ~ DATJ!BI31/2005
'-..-I ~b'Mt6ift sh R, appinger Falls, NY 12590
STREET CITYITOWN STATE
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE o~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED 9 0 OTHER, SPECIFY
w
en
z
w
o
:::i
YEAR
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Dl t-t< VlQ<:
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF b( VILLAGE OF
SPECIFY '\/1 r C' pp \' I) J f>r \
FQ\\ )"
NAME (PRINT)
SIGNATURE ~ '