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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1. A FULL NAME ~ DavictJJfJ*
COUNTY DuIdl..
CITYriOWN Wappinger:
DISTRICT
NUMBER ~ 388
REGISTER 81
NUMBER
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~
2. RESIDENCE A. N~arIc B. ~IB
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY East FISbIdU
D. STREET ADDRESS !l11 ThIrd Roed ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES.;J NO
JIJH /2a /1111
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
3B. DATE OF BIRTH
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3. A. AGE43
4. EMPLOYMENT
A. USUAL OCCUPATION Coa'ection Officer
8. TYPE OF INDUSTRY OR BUSINESS ~er County
5. PLACE OF BIRTH~ !fM y~
( ,re I A)
6. FATHER
L 0 SUPPLEMENTAL FILE
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A. NAME stephen Joha Tumer
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Jo8n Debor8h Rose
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
11. A.
FROM THE BRIDE
FULLNAME Nag Cheryl ~
CURRENT SURNAME
001
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) r! DEATH
C. DATE LAST MARRIAGE ENDED? M / ~ / ')IV'l':t
MONTH""" ~ ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES @l 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
B. BIRTH NAME (MAIDEN NAME}, IF DIFFERENT Dennis
C. S~S~~~J~rz~~~:~~e~~s1'umer
D. SOCIAL SECURITY NUMBER 1 03 38 0378
12. RESIDENCE A~JIIlIA~ B. ~~
C. CHECK ONE 0 CITY fiI TOWN 0 VILLAGE
~~CIFYRoughkeepM
D. STREET ADDRESQA lod street ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rI!J NO
13 A AGE58 13.B. DATE OF BIRTH 1\1;. .fa ....(~'7
. . '~NTH rlq DAY I If4I 'EAR
14. EMPLOYMENT
A. USUAL OCCUPATIONTeecber
B. TYPE OF INDUSTRY OR BUSINESS VVapp Scb [)1st
15. PLACEOFBIRTH~Yodc
16. FATHER
A. NAME Harald Den_
B. COUNTRY OF BIRTtt I S A
17. MOTHER
A. MAIDEN NAME \Arglnl8 G\aJ8Rdolyn ShIpley
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) r! DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? "0 / n.t /1QQf:t
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D. ARE ANY FORMER SPOUSE(S) ALIVE? r!tYES 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
o 0 1ST 1W04f1MPoughkMpIIe, NY
o 0 2ND
o 0 3RD
o 0 4TH
ed e and belief that the information
~ 0
o 0
o 0
o 0
a no legal 'mpediment 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 St e of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within ew 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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21. SIGNATURE OF GROOM ~
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{ SEAL }
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NAME (PRINT)
SIGNATURE ~
MAILING ApDRES
25. B. SOLEMNIZA TIONPERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
YEAR
MONTH
DAY
YEAR
DATE ~1n7nnn5
10:08 AM 07
PM
08
2005
09
05 2005
ZIP
C
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
SA
27. TYPE OF CEREMONY
RELIGIOUS
10 CIVIL
A. STATE NEW YORK B. COUNTY ll/At(he~)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF )Q VILLAGE OF
SPECIFY vJnppr 0ajffS fQI15
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
9 0 OTHER, SPECIFY
NAME (PRINT)
SIGNATU
DOH-98 (11/98)
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ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~