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COUNTY [)utc~
91TYITGWN Wappinger
IblSTRICT 1358
NUMBER
REGISTER 20
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard James Beltmund
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Ramands Sue Bowman
~
,. A. FULL N~ME
,1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 133-70.5473
O. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York .B. Dutchess
(STATE)....J. . (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappin~
o. STREET ADDRESS 87 mlth Crossing Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 25 3B. DATE OF BIRTH 01
MONTH
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bellmund
(OPTIONAL - SEE REVERSE) 288-7D.3648
O. SOCIAL SECURITY NUMBER U"
12. RESloENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY D-fOWN 0 VILLAGE
AND W .
SPECIFY 8PP1nger
o. STREET ADDRESS 8? Smith Crossing Road
13.B. DATE OF BIRTH
ZIP 12590
YES d" NO
A 980
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
11 /25
MONTH DAY
13. A. AGE 24
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Registered Nurse
B. TYPE OF INDUSTRY OR BUSINESS Danbury Hospital
15. PLACE OF BIRTH Gallon. Ohio
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Ronnie Rav Bovvrnan
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Chem Lynn MQyAf
B. COUNTRY OF BIRTIH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS FEN Enterprises
5. PLACE OF BIRTH Carmel. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Richard A Bellmund
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Joan Dunes
s. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
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
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
YEAR
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that
as to my right to enter into the marr'
21. SIGNATURE OF GROOM
o
o
o
o
y knowledge and
o 1ST 0 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
. f that the information I provided is true and that I declare that no legal impediment exists
22. IGNATURE OF BRIDE ~ ~i-J "'--j.(}-'n /1)( .b..)
. t:;;J.IZ.USE CUf'i~
W
en
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W
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23. ~~J'fr~~~Do~N1o~~Oo~ ~~Bg~~~~E DATE 03l2312OO5
This license authorizes the marriage in New York State 0 the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne ork 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
{ } NAME (PRINT)GI -. J. ~orse - TIME MONTH
SEAL SIGNATURE ~ .~, DATE 03
'-v-I MAI:m' ~rtD~ R B Falls NY 12590 10:5W'M 03
STREET CITY OWN STATE ZIP PM
~~~R~~~RT~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTlHER, SPECIFY
YEAR
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AN~PECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
29. OFFICIANT
NAME (PRINT)
SPECIFY
NAME (PRINT)
SIGNATURE ~