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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Matthew C. Glover
o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
Dwledge and belief that the in ormation I provided is true and that I dec are that no legal impediment exists
22. SIGNATURE OF BRIDE ~ V:u1~11l'v1 .~ttbJ\a~
~R~ME
23. ~::~:T~=~DC:Nf~O~ ri(i.!~~i~E DATE 0812712004
This license authorizes the marriage in ate of t e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi n 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 CITYGlCLEItK J 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) ana.
COUNTY Dutchess
CITYfTOWN -:;pPngtM
DISTRICT 1
, NUMBER
REGISTER 108
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 074-68-2494
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) ...J (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN LI VILLAGE
~~~CIFY Wa~1II1s
D. STREET ADDRESS .Street ZIP 12580
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? c:1' YES 0 NO
3. A. AGE 23 3B. DATE OF BIRTH 02 / Zl / 1981
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION lr~an
B. TYPE OF INDUSTRY OR BUSINESS Metro North
5. PLACE OF BIRTH a.acon. NeW York
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME George JudBan Glover, III
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gloria Jean Quirk
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNUUMENT
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 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
21. SIGNATURE OF GROOM ~
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{ SEAL }
SIGNATURE ~
MAI~
08fZl
F.ns NY 1~
08
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Erica M. ZUbradt
-.J
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), I F DIFFERENT
C. SURNAME AFTER MARRIAGE Glover
(OPTIONAL - SEE REVERSE) 078-70-8826
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN U"'VILLAGE
D. :~:~;AD:~=-=- ~P 12580
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r:I YES 0 NO
13. A. AGE 25 13.B. DATE OF BIRTH 10 /26 /1978
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Bookeepi~~tAssistant
B. TYPE OF INDUSTRY OR~ 0 S Management
15. PLACE OF BIRTH Mount KIsoo. New York
(CITY, STATElCDUNTRY IF NOT USA)
16. FATHER
A. NAME Gerald ZUbnKI
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME DorIs Kuran
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
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
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
TIME
MONTH
YEAR
ZI
AM
02:36PM
TRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A E
27. TYPE OF CEREMONY
o [lY1'\ELlGIOUS
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYbc.rrr:#{~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY c: ,'::;H UJ LI.,-
t ,.....
CITYrr WN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
o i 0 s-: AM ~ - ;).5' - 0 '-I 9 0 OTHER, SPECIFY
:~~::~A'.~~~J:f:. : rr;; t1/t
MAILING ADDR~ ..' /) ,1 L7I
g()(o f'nt},;J St; \ rOt16-Hldq!JS, f' J KJ 7 Idf::,o3
STREET CfTYfTOWN STATE ZIP
30. WITNESS TO CEREMONY 31. WITNESS TO CEREMO Y
NAME (PRIN
NAME (PRINT)
SIGNATURE ~