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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Joshua S. Crum
MIOOlE CURRENT SURNAME
COUNTY ~
CITYfTOWN Wappinger
1'368
143
OI~TRICT
~MBER
REGISTER
NUMBER
1. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 111:: ~D0866'
D. SOCIAL SECURITY NUMBER ~
2. RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY []!frOWN 0 VILLAGE
AND We'
SPECIFY DDlnaer
D. STREET ADDRESS 13 Wldwood Drive
ZIP 12590
o YES []I NO
....
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E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 26 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Marketing
B. TYPE OF INDUSTRY OR BUSINESS R68d ExhllitlOM
5. PLACE OF BIRTH ~'5!t~F"~)T~!r' York
6. FATHER
A. NAME Franklin Chartes Crum, Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME rlAnlg MArie ~coIls
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNOLMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? ~3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH OA Y 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, OAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the marri
21. SIGNATURE OF GROOM ~
23.
o
o
o
o
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{ SEAL}
'-v-I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M~~n E Mcc~r:~ SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Cmm
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 119-72.3339
12 RESIOENCEA. N~Erork B. 9~P.5la
C. CHECK ONE 0 CITY D.tOWN 0 VILLAGE
AND P h~
SPECIFY oug .........,...."..e
D. STREET ADDRESS 50 Del BAI~ BouhwArd
13. A. AGE 24
ZIP 'i25gQ
YES o."NO
/1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MOQl / Q1
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Pslyr.hnlQgV
B. TYPE OF INDUSTRY OR BUSINESS VAIA Naw Hev$n
15. PLACE OF BIRTH (~.MF~N!N York"
16. FATHER
A. NAME Dougln Andrew Mr. Neil
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Dana Jeann.Mattlck:
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH OA Y 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
o 0
o 0
o 0
DATE 12ft11/2D04
by New York Domestic
.TIME MONTH DAY YEAR MONTH YEAR
AM
03:Q5PM 12, 02 01 30 2005
2B. PLACE WHERE MARRIAGE OCCURRED
CIVIL NEW YORK COUNTyD..j1Ct\~SS
A. STATE B.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY 1tJa~~~ ~\ \~
ZIP
31. WITNESS TO~REMONY
NAME (PRINT) to /l1 do...
SIGNATURE ~ fl.