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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
Don,i~~tt~W~~OOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
Dutchess
COUNTY Wappinger
CITYfTOWM388
DISTRICT ~
. ~~~I~~~R 50
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME . Lynn Fsher
FIRS MIDDLE
CURRENT SURNAME
1. A. FULL'NAME
11. A.
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Fsher...Cbnith
(OPTIONAL - SEE REVERSE)111 ~~
Q. SOCIAL SECURITY NUMBER -:JL-585Q
12. RESIDENCE A.New York
(STATE)
C. CHECK ONE 0 CITY~ TOWN 0
~~CIFYFIShIdII
D. STREET ADDRESS P. O. Box 565
C. SURNAME AFTER MARRIAGE .
(OPTIONAL - SEE REVERSE)131-~
D SOCIAL SE~&rc DulChe8S
2. RESIDENCE A. (STATE) tI B. (COUNTY)
C. gJ~CK DNFlShlll CITY 0 TOWN 0 VIllAGE
SPECIFY P. O. Box 518
B.~
VILLAGE
ZIP12511
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES'llJ NO
13. A. AGrA7 13.B. DATE OF BIRTH no n ..nf.,
~NTH DAY "'~EAR
14. EMPLOYMENT
A. USUAL OCCUPATIOI'Medical Un".., Pmr"'--....
B. TYPE OF INDUSTRY OR BUSINEssC8stIe PaInt V A 1-1
15. PLACE OF BIRT~ PI8Ins.New Vark
(CITY, STATE/COUNTRY IF NOT USA)
ZIP 12511
YES ~ NO
/1948
YEAR
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D. STREET ADDRESS
E. IS R~E WITHIN UMITS OF CITY OR lNCORPORATE'trf"GE? 0
3. A. AGE 3B. DATE OF BIRTH ,.A)8
MONTH DAY
4. EMPLOYMENT Maintanence Work8r
A. USUAl OCCUPATION c..ae Nit V A H
B. TYPE OF IND~Seclh.~
5. PLACE OF BIRTH ·
(CfTY, STATE/COUNTRY IF NOT USA)
6. FATHER Alden Donaldson Smith
A. NAME U 8A
B. COUNTRY OF BIRTH
16. FATHER
A. NAM~n Pal,jFISher
B. COUNTRY OF BIRTUS A
17. MOTHER
A. MAIDEN NAM~.IY AtWll"A Crendell
B. COUNTRY OF BIR.JJ S A
18. NUMBER OF THIS MARRIAGE 2
7. MOTHER GlIdys Emma BerwIII
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 2
8. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0 0
B. HOW DID lAST MARRIAGE END? (3)0 DIVm '~NULM,9i!f DEATH B. HOW DID lAST MARRIAGE END? (3~ DIVORCE (3) 0 ANNULMENT (2)0 DEATH
C. DATE LAST MARRIAGE ENDED? MOrtltt _ DAY - YEAR C. DATE LAST MARRIAGE ENDED? MOf!] ~Y ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 'W'(] YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
OIfI25#'995"Podgfil.jiHr~ork ,.LF SPOUSE ~~R) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST · 0 0 1S~.!.; Pauahk8eD51e. NY 0 IlIIItJ
2ND 0 0 2ND 0 0
~ 0 0 ~ 0 0
~ 0 0 ~ 0 0
I, being duly swom, depose and say' that to the best of my knowledge a belieL!.hat the information I provided is true and that I declare hat no legal impediment exists
as to my right to enter into the mar' estate. ·
21. SIGNATURE OF GROOM ~
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1'fRCE CIVIL1rULMENT
~
...
DEATH
DciATH
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ENT NAME
DATtB/'ZlJ2fXY5
by New York Domestic
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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 Stat 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 ORJOfttiLC~Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) -f}
SEAL :Ii~[~~rr~ 1 :5~IME A
~ . P
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER. SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~