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ST ATE OF NEW YORK I STATE FILE NUMBER I
COUNTY Dutchess (THIS SPACE FOR STATE USE ONLY)
CITY/TOW1~nger DEPARTMENT OF HEALTH
DISTRICT AFFIDAVIT, LICENSE and
NUMBER
, REGISTER 119 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FUll NAME Christopher P. Booth 11. A. FULL NAME C~R. L O~NT SURNAME
FIRST MIDDLE CURRENT SURNAME FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 084-60-4254
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. nutr.hMla
(STATE) ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
D. :~:~~AD:~=:" ROIdAli. H10zlP 12803
1:. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
M~ /~l /12T'
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~
(OPTIONAL - SEE REVER~'
D. SOCIAL SECURITY NUMBER 11s..n..0534
12. RESIDENCEA. ~r~ork B. D~
C. CHECK ONE 0 CITY ~TOWN 0 VILLAGE
AND 0 gb~
SPECIFY rOI' ~e
D. STREET ADDRESS 24 Del Bllso Boulevard ZIP 12&90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 22 13.B. DATE OF BIRTH m., /13y 19112
14. EMPLOYMENT
A. USUAL OCCUPATION Cedified Nullling ...At
B. TYPE OF INDUSTRY OR BUSINESS WngMe N. Dutchess
15. PLACE OF BIRTH ~~_. YOIt
16. FATHER
A. NAME Air.hllrd Fl1Ink Obemt, Jr.
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME GullA Kim M8FFI5en
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
3. A. AGE Zl
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Assistant Store ManaSJer
B. TYPE OF INDUSTRY OR BUSINESS MlcheeI's Arts & craftS
5. PLACE OF BIRTH Carmel. New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Frederick S. Baath
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME . Uncll Meryte PerMklwA
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V~CE CIVIL ANBULMENT
o
(2) 0 DEATH
DEATH
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH .
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULlED, 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
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
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say,
as to my right to enter into the marr'
21. SIGNATURE OF GROOM ~
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22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEI;ORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This Iicens!,! authorizes the marriage in New York S te of th bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies with' New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is 0 be used only for the pur ose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CIoERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona J. ~
u TIME MONTH DAY YEAR
SEAL SIGNATURE ~ -- 'Tm/1712D04
~ ~WiBIitiush Rd, Falls NY 1 0".25 AM
STREET OWN s ATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE O~RELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. Oi " 9 0 OTHER, SPECIFY
DATE
by New York Domestic
MONTH
YEAR
18
2004
1 D CIVIL
28. PLACE WHERE MARRIAGE '1)URR D
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY fn uc.h k e fp 5; e
"J p
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~