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COUNT'oO Dutchess
CITYrrOWN Wappinger
DISTRICT 1388
NUMBER
~B~~J~R 114
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Walter A Clarke III
MIDDLE CU~RENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nicole M. Di Pada
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) ~J:H\_fY780
D. SOCIAL SECURITY NUMBER ~i71
2. RESIDENCE A. New York~ B. Outme.a
(STATE). ~
C. CHECK ONE 0 CITY tY'TOWN 0 VILLAGE
AND p_, ._..a.-...._;
SPECIFY UUWlI~e
D. STREET ADDRESS 31 Salt Point TumDlke ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r! NO
11 / OS / 1976
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Clarke
(OPTIONAL. SEE REVERSE) 1"=11n.~..3161
D. SOCIAL SECURITY NUMBER _~____
12. RESIDENCE A. New York 8. nlJtchess
(STATE) ""'1mNTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
;~CIFY PoughkeeDBie
STREET ADDRESS 31 Salt Point TumDlke ZIP 12603
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rI NO
OS /16 AM:t
MONTH DAY YEAR
D.
E.
13. A. AGE 21
3. A. AGE "Zl
13.8. DATE OF 81RTH
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Lube Manaaer
B. TYPE OF INDUSTRY OR BUSINESS Foam & Wash
5. PLACE OF BIRTH I)m~,. NAw York
iCITY7S1'ATi:Jc0u~F NOT u~i'
6. FATHER
A. NAME Walter Archibald Clarke. Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Bonnie LM Race
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
14. EMPLOYMENT
A. USUAL OCCUPATION Domestic Enpineer
8. TYPE OF INDUSTRY OR BUSINESS Housev.Me
15. PLACE OF BIRTH fc.~~~o~ York
16. FATHER
A. NAME JaseDh Ravrnond Di Pada
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME ~orIa OfJI--ntra
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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?
(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 ANNULED, 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
w
U)
z
w
()
::i
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~D 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is tru
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~ .
23. SUBSCRIBED AND SWORN TO BEPORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S
Relations Law ~11 to perform marriage ceremonies with;
o If checked, this license is
~ 24. TOWN OR CITY CLERK
{ } NAME (PRINT) Gloria J.
SEAL SIGNATURE ~
MAI~ t.f&jS
'-.t-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. :60 C:> ( 0
~~~li~~~~L-=:R ~'L \ko '" c:;. ~ L. HA' t\ !jrITLE t:> c..~ .(-0 ...
SIGNATURE~ D~..a.crc ~ l.-l-~ DATE .<"",D\- l~ 2~o<...f
MAILING ADDRESS 0 ~ J
""1.. Ccr_~\r~ f<..l. .....'^~..."L\o'LJc.. tJ.V. r2.S':r''L
STREET CITYfTOWN STATE ZIP
30. WITNESS T~REMONY .f\"\~ 31. WITNESS TO C EMONY
NAME (PRINT) ~ ~ NAME (PRINT)
SIGNATURE ~ ~ SIGNATURE ~
DOH-98 i 11/98\
o
o
o
TIME MONTH YEAR
AM 09
IP 01 :09PM
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL NEW YORK '^JAcJ'S
A. STATE 8. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF i!3""rOWN OF 0 VILLAGE OF
C. \ \ ""\- Q, ......
SPECIFY