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COUNTY ~
CITYfTOWN Wappinger
DISTRICT 1388
/;UMBEFl
, ~G~~J~R 118
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~I!e J. Muogsvin
MI OLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
MID~cty FortinCURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
RRST
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B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE MuDglBlin
(OPTIONAL - SEE REVERSE) ~1lI ~ ~11 9
D. SOCIAL SECURITY NUMBER ~.;!_ __
12. RESIDENCE A. NlutVork: B. nutm-
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C. CHECK ONE 0 CITY OIllltOWN 0 VILLAGE
AND I......
SPECIFY~1f"PP~
D. STREET ADDRESS 1 G Alpne DrIve
C. SURNAME AFTER MARRIAGE
D. Sci~~~I~~~R;~E~U~~RSE) 081-62.50[)5
2. RESIDENCE A. NBNYork B. nutm-
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C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
~~~CIFY WaDDinger
D. STREET ADDRESS 1 G Alpine DrIve
ZIP 12590
DYES c1' NO
ZIP 12590
YES ~NO
~~
E. IS RESIDENCE WITHIN UMrTS OF CITY OR INCORPORATED VILlAGE?
3. A. AGE 26 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Environmental Consultant
B. TYPE OF INDUSTRY OR BUSINESS Envlrologlc
5. PLACE OF BIRTH \MlIte Plllns. New York
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME JoBeoh John MUngavin, Jr.
B. COUNTRY OF BIRTH USA
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0
MOW: / =m
13. A. AGE 7ft
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Landmark Academy
15. PLACE OF BIRTH ~~E1~~ONr' York
16. FATHER
A. NAME Jean G~ Fortin
B. COUNTRY OF BIRTH CAnada
17. MOTHER
A. MAIDEN NAME allr. LlgLMH.IX
B. COUNTRY OF BIRTH CAnada
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
7. MOTHER
A. MAIDEN NAME S.l&An AnnA Mr.
B. 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
M~ MY Y~R
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
(3) 0 ANNULMENT
/ /
(2) 0 D~TH
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2ND
3RD
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DATE 09I16f2004
person authorized by New York Domestic
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TIME
MONTH
YEAR
ATE 0911
ails NY 12590
STA E
27. TYPE OF CEREMONY
o ~IGIOUS
9 0 OTHER, SPECIFY
AM
12:03='M
09
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIM AND
PLACE INDICATED.
ZIP
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Il""'TO"WN OF 0 VILLAGE OF
, .
SPEClFY-&gSr Pr 6111.1 ij..,
NAME (PRINT)
SIGNATURE ~