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COUNTY Dutchess
CITYITOWN Wappinger
~~~~~c~ 1368
~5~I~J~R 136
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David Allen Mal'CQjohn
MIDDLE CURFlENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Usa Jane Benedct
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE MarcQjohn
(OPTIONAL - SEE REVERSE) ~A54-4171
D. SOCIAL SECURITY NUMBER ~----
12 RESIDENCE A. N Y B nllt~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND We .
J>~E~PL ........pal'l$l8f' .... ........
o STREET ADDRESS 12 Be8ttY Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r! NO
13. A. AGE 37 13.8. DATE OF BIRTH OS /os ,If'QR7
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Residential11lerapist
8. TYPE OF INDUSTRY OR BUSINESS Rehab. Inc.
15. PLACE OF BIRTH Poumltwimde. New York
(CITY, ~A;:E7CouJTRv.IF NOT USA)
16. FATHER
A. NAME Wayne Benedd
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Prlsdlla Haggerty
8. COUNTRY OF BIRTH USA
1B. NUM~ER OF THIS MARRIAGE 1
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 122-I:D-Cf/35
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE ANY B. Dutchess
(STATE).J (COUNTY)
C. CHECK ONE 0 CITY L:'l' TOWN 0 VILLAGE
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D. ST~E~ ADDRESS 12 Beatty Road . ZIP 12590 .... ..
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
11 /22 /1959
MONTH DAY YEAR
3. A. AGE 44
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION 8ectrical \Norker
8. TYPE OF INDUSTRY OR BUSINESS PhoenIx Slanal & Bee.
5. PLACE OF BIRTH Poughkeepsie. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME William Thornas Marcojohn
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Barbara Marie Lahey
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DEATH
100 0
B. HOW DID LAST MARRIAGE END? (3) rf DIVORCE (3) 0 ANNULMENT _il.P... DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 06 / 30 / 2W".:I C. DATE LAST MARRIAGE ENDED? / /
MONTHJ DAY YEAR MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? aYES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
(MONTH. DAY. YEAR) (CITY a:TATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1 ST 06130I2OO3 Dutchess Co., N Y 0 r!! 1 ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the mar' Ige sta~. -I A ~ _ J2 /l " ~
21. SIGNATURE OF GROOM ~ ~ 22. SIGNATURE OF BRIDE ~ tY.J()(J- ,T(j()1./l. t::.JJI./?1.t1~
, USE CURRENT NAME
DATE 1Of12f2004
by New York Domestic
YEAR
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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 State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New 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 CI-o:.~LEElK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) UlonaJ.
{ ~ ~
SEAL SIGNATURE ~ \-
'-v-' M~ ... Rd, AM 10
STREET ZIP 01 :52 PM
I CERTIFY THAT 1 SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
NAME (PRINT)
SIGNATURE ~
DOH-9B (11/98)
(PRINT)
SIGNATURE ~
,Ill CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY Po l..)~ ~)z-eo ~ ',€,
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