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CITYrTOWN Wappinger
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1. A. FULL NAME
ST ATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
KYJIs~nder:sonJlftck
CURRENT SURNAME
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME BramW Marie HI~rt
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl..
o SOCIAL SECURITY NUMBER --tJ56 12 1689
2. RESIDENCE A. N.AX1olic B. D~SI
C. CHECK ONE 0 CITY..ll TOWN 0 VILLAGE
ANDn J..k .
SPECIFY rOUgH eepsle
o STREET ADDREss374 ~hp.AfP. Rosul ZIP 12S!:m
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESt(] NO
~H /2iy /1~~
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rlack
(OPTIONAL - SEE REVER~
o SOCIAL SECURITY NUMBER 11 9 74
12. RESIDENCE ANewrXelic
C. CHECK ONE 0 CITY ~ TOWN
ANOn J..k .
SPECIFYrOUgl-l eepsle
D. STREET ADDRES~74 ~hp.!Rfp. Road zIP1259n
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES-l] NO
13.B. DATE OF BIRTH 02. ../... "../...r:.
illIONTH ENS DAY · tHS"i'EAR
0024
B.0'4_1
o VILLAGE
38. DATE OF BIRTH
13. A. AG!:20
14. EMPLOYMENT
A. USUAL OCCUPATIONUnemployed
B. TYPE OF INDUSTRY OR BUSINESS
3. A. AGE26
4. EMPLOYMENT
- -A-:- uSUAL OCCUPATION EledriciaR
B. TYPE OF INDUSTRY OR BUSINESS Elite
5. PLACE OF BIRT.e~_~c~e~~~ -l Yo~
6. FATHER
15. PLACE OF BIRT.e~~~~~IF hI Yo~
16. FATHER
A. NAMEMichael Hemert, Jr.
B. COUNTRY OF BIRTIlI '5 A
17. MOTHER
A. MAIDEN NAMEDBWR Marie Rende
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
n 0
DEATH
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A. NAME William Anderson Black
B. COUNTRY OF BIRTH II '5 A
7. MOTHER
A. MAIDEN NAME SUlsn Bea Kidder
e. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH OAY 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
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
1D. 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
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1ST 0 0 1ST 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 t B best of my knowledge and belief that the information I provided is true and that I declare that no legai impediment exists
as to my right to enter into the mart' ge state, I J II \
21. SIGNATURE OF GROOM ~ OF BRIDE ~ ~/.mdiA.IdI?' V~~
o USE CURRENT NAME
~ ~~~
This license authorizes the marriage in New York State of the 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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YEAR
YEAR
MONTH
NAME (PRINT)
TIME
MONTH
AM
pM 08
25
2005
10
23 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUN.;:d2&CTC1ftJIZ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) . ./
o CITY OF 0 TOWN OF ~llLAGE ~
SPECIFY 1I\J~~t~~
NAME (PRINT)
SIGNATURE ~