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Dutchess
COUNTY we
CITYITOWI\Ii pPlnger
DISTRICT. ,..-
NUMBER
REGISTER 100
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John F. Siller, JR
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
DiolindB L..ackard
--3
1. A. FULL NAME
11. A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) tJ9:)-~ 1136
D. SOCIAL SECU~~R
2. RESIDENCE A. ark B. DutchesB
(STATE) r.ITV ~ (COUNTY)
C. gjgCK ONEWaPPi~ TOWN 0 VIUAGE
SPECIFY 33 HeI DrIVe
D. STREET ADDRESS en
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER.MARRIAGE L..ackBrd
(OPTIONAL - SEE REVERSE) 059-66-1704
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) Ji (COUNTY)
C. CHECK ONw. D. CITY IT TOWN 0 VIUAGE
~~CIFY ppnger
D. SmEET ADDRESS 33 Helen onve ZIP 12tiW
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rf NO
1~.. A. AGE 38 13.B. DATE OF BIRTH 12 /03 .A965
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Union Insulator
B. TYPE OF INDU~fl~.ill!. UI~L~ .1
15. PLACE OF BIRTH NOrUl Ilrrywwn. NeW York
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME Ronald David L.ackard
B. COUNTRY OF BIRTH U 6 A
17. MOTHER
A. MAIDEN NAME Evelyn Rose Ferguson
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE ;,
12590
ZIP
YES r5 NO
/1960
YEAR
E. IS RESll~E WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? f
3. A. AGE 3B. DATE OF BIRTH 10 / 1
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
5. :~;:~:,:~U~Rtf&l\lle~C: 13
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER Joh Fredri Sill
A NAME n c er
B: COUNTRY OF BIRTH USA
7. MOTHER A... F 8.......__
A. MAIDEN NAME Milne ranees ggl MoI\NGI
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
D~H
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V~RCE CIVIL AN~LMENT
.,
B. HOW DID LAST MARRIAGE END? (3) 0 DIVOR~... (3) D~fiNULMENT ....(~ r;J DEATH
C. DATE LAST MAF.lRIAGE ENDED? W / U4 / ~
MONTHIlII' DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? a YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
~.~. (CITY, ATElCOU ;:'~v 'brk SELF SPOUSE
06ID4I20D4 ~York ~
o
o
ent exists
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO.CE CIVIL AN~LMENT
.;
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORTJ3 (3) 0 tf~ULMENT . DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONT~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE T1HE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(M16{~ ~:'fMt~brk SELF SPO~ 1ST
o 2ND
o 3RD
o 4TH
belief that t e information I provide
DEOH
1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa
as to my right to enter into th .
,.
21. SIGNATURE OF GRooM~.
w
en
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:::;:j
23. SUBSCRIBED AND SWORN ORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license 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 withi 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 Dr subsequent ceremony,
24. TOWN OR CI~lEElK J. 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
08120I2OO4
DATE
by New York Domestic
DATE 08120I2OO4
Falls, NY 12590
AM 08
02:39 PM
~
{ SEAL }
'-v-I
YEAR
TIME
MONTH
SIGNATURE ~
M
ZIP
STA E
27. TYPE OF CEREMONY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~~'-.;
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY~' II. ~e r-
STREET
I CERTlfi'Y THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
l:&r'CIVIL
29. OFFICIANT
NAME (PRINT)
SIGNATURE ~