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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bradl~ A Canson
MIDDLE CURRENT SURNAME
1ST
2ND
3RD
4TH
I, being duly sworn, depose an say, that to t e best of my know edge an
as to my right to enter into the ~.~age state... ~'
21. SIGNATURE OF GROOM~ C~
SE CURRE NAME
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 onl for the purpose of a second or subse uent ceremony.
~ 24. TOWN OR CITY CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glon J
{ ~ ~
SEAL SIGNATURE ~ .' DATE 08I23f2004
'-.t-I M~1OO~~bush Rd, W 'n r Falls, NY 12590 03:11 ~~ 08
STRE T I OWN TA ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND A
PLACE INDICATED. 8 _ ;;. b - OL{ 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:f: 1368
~5~~J~R 102
1. A. FULL NAME
FIRST
c.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 5n 583
D. SDCIAL SECURITY NUMBER 124- ..,..5
2. RESIDENCE A. N v B. 01 Jtl'h~~
(!-rATE) (~)
C. CHECK ONE 0 CITY r!!f TOWN 0 VILLAGE
~~~CIFY WaDDinaer
D. STREET ADDRESS 23 0 Camaby Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 45 3B. DATE OF BIRTH 11 /1R /1958
MONTH DAY YEAR
4. EMPLOYMENT
A USUAL OCCUPATION Groundskeeoer
B. TYPE OF INDUSTRY OR BUSINESS Crotonlharmon Schl. D1st.
5. PLACE OF BIRTH Mineola. L I.. New York
(CITY, STATE/COUNTRY IF NOT USA)
....
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ClI.L
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6. FATHER
A. NAME Donald Car1son
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Patricia Farish
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
1
(3) 0 ANNULMENT (2) r1 DEATH
/1998
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED? 06 / 24
MONTH JAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ~ 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
w
en
z
w
o
:::::i
29. OFFICIANT
NAME (PRINT)
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A. FULL NAME FIRST Cynt~J~E S 0'1 OIJ~t:.~PNT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT ShAW
C. SURNAME AFTER MARRIAGE C~lIfl~n
(OPTIONAL. SEE REVERSE) 13'34" 1344
D. SDCIAL.SECURITYNUMBER --~-~--
12. RESIDENCE A. N ~TATE) B. \^{M~ester
c. CHECK ONE 0 CITY iY TOWN 0 VILLAGE
~~CIFY Lewisboro
D. STREET ADDRESS 10 Meadow' street ZIP 10526
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13.A. AGE 41 13.B.DATEOFBIRTH 10 /?5 ~
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Homemaker
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Mt. Kisco. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME James Weslev Shaw
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Virginia \Nhittet
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) r1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05 / 28 /2004
MONT!:1; DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? IJ 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
1ST 0512812004 Westchester Co.. N Y ~
DEATH
o
o
o
,
Domestic
YEAR
1)(' CIVIL
28. PLACE WHERE MARRIAGE OCCURR~~
A. STATE NEW YORK B. COUNI/J~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF pO~N OF 0 VILLAGE OF
SPECIFY~~
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~