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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~ERidlard G.a SURNAME
COUNTY Dutchess
CITYfTOWN \A'appinger
DISTRICT . .
~~~I~~~R 1368
NUMBER 145
1. A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 102 .62- 3866
B YIRf
~ TOWN 0 VILLAGE
2 RESIDENCE A. N it
(S ATE)
C CHECK ONE 0 CITY
AND
SPECIFY
Highland
D. STREET ADDRESS 235 Upper North Road ZIP
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MOt1~ / 28
12528
YES ~ NO
/~
::; I A I t:. t"ILt:::. NUMI::n:.H
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
C~l,en MurdQQtm SURNAME
~
3. A. AGE 42
4. EMPLOYMENT
38. DATE OF BIRTH
11. A. FULL NAME
FIRST
A. USUAL OCCUPATION TruGlc DFiver
8. TYPE OF INDUSTRY OR BUSINESS Exxon Mobil
5. PLACE OF BIRTH ~tMw ~..)
6. FATHER
A. NAME 'Actor Jehn Chain
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Darbera Anne Niver
8. COUNTRY OF BIRTH U S ^
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT RobiRSBR
C SURNAME AFTER MARRIAGE "'haiR
(OPTIONAL. SEE REVERSE""
D SOCIAL SECURITY NUMBER 072 56-8339
12. RESIDENCE A. N ~ATE) B. ~)
C X~6CK ONE 0 CITY q;TOWN 0 VILLAGE
SPECIFY Highland
D STREET ADDRESS 235 Upper North Road ZIP 12528
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
M03 /2Sr -1959
13. A. AGE 46
14. EMPLOYMENT
13.B. DATE OF BIRTH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? na / 'Xl: / .....000
MONTH ug D/ff"- \1;_-
D. ARE ANY FORMER SPOUSE(S) ALIVE? [JwII'ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
A. USUAL OCCUPATION Radiology RepreseRtative
8. TYPE OF INDUSTRY OR BUSINESS Klngsten HO$pltal
15. PLACE OF BIRTH ~O~"' reM)
16. FATHER
A. NAME CaFSDA Dean Robinsen
B. COUNTRY OF BIRTH U S I-
17. MOTHER
A. MAIDEN NAME Rita Marie Me C8ffer,'
8. COUNTRY OF BIRTH U S ^
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
8. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? "'0/ otR / ~
MONTH I DItI'" ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? [JwII'ES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
o Q; 1 ST 1011612002 Poughkeepsie, N Y 0 ~
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
owledge and belief that the information I provided is t~n~ ;ha~ I declare that no iegal Impediment eXists
22 SIG ATURE OF BRIDE ~.GML!J? ~~ ./'!J4i' .I/Jdo-- ~
J1t. USE CURREN AME
23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK DATE
This license authorizes the marriage in New York Sta authorized by New York Domestic
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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0812611999 Peugt-akf)epsie. N Y
21. SIGNATURE OF GROOM ~
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{ SEAL }
~
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
AM
PM
21
02
18 2005
12
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
. ATE
27. TYPE OF CEREMONY
RELIGIOUS ~IVIL
9 0 OTHER, SPECIFY
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTvUU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OFO<(TOWN OF 0 VILLAGE OF
SPECIFY L-l...tJ' Y A
TI~~,J~
DATF/' ~..~ J:)-~
/ :rJ-~
ZIP
31. WITNESS TO CEREMONY
J
NAME (PRINT) t'"
SIGNATURE ~