092
STATE OF NEW YORK I STATE FILE NUMBER I
(THIS SPACE FOR STA fE USE ONL Yi
COUN;v' Dutcbe!$ DEPARTMENT OF HEALTH
I,CITYfTOWN Wappinger
, 2~J~kc~ 1368 AFFIDAVIT, LICENSE and
~5~~l~R 92 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Ch~ c. ~.URNAME 11. A. FULL NAME ~ T. IIay_RRENT SURNAME
FIRST FIRST
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 176-62-1258
2. RESIDENCE A. P~al1i. B. ~r
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND Q.....i C~iiu
SPECIFY -~.ng ...,
D. STREET ADDRESS 819 Pugbtown Road ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
Mm / 16
1t475
YES ~ NO
/W65
3. A. AGE 39
4. EMPLOYMENT
A. USUAL OCCUPATION SIlls
B. TYPE OF INDUSTRY OR BUSINESS Self EmJll~td
5. PLACEOFBIRTH ~~~.
6. FATHER
3B. DATE OF BIRTH
A. NAME VVayne steljing
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Karen eerllGY$ky
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
B. HOW DID LAST MARRlAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
DEATH
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
MONTIi 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
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ftL-1rI.."""
(OPTIONAL. SEE REVERSE~ ",.,
D. SOCIAL SECURITY NUMBER 128-64-0573
12. RESIDENCE A. P~"ill B ~
C. CHECK ONE 0 CITY Q,;TOWN 0 VILLAGE
AND .
SPECIFY SpRAg City
D. STREET ADDRESS 819 Pyght8l:m Read ZIP 19475
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
a . / my 1..
13. A. AGE 38
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION f'rejeet Msnsger
B. TYPE OF INDUSTRY OR BUSINESS PhyseIIM OIet;/lllln"
15. PLACE OF BIRTH Y~IL.NIMI' )r-ork
16. FATHER
A. NAME FF8neis Hayes
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Frlnce5 Topham
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
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(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
o 0
o 0
o 0
o 0
pediment exists
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say' t t
as to my right to enter into the mar' ge "
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Sta person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
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. SIGNATURE OF BRIDE ~
TIME
MONTH
NAME (PRINT)
SIGNATURE ~ _.
MAILING ADDRESS
AM
PM 08
08
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM-
3:00PM 08/08/04
, AT
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1 IKI CIVIL
A. STATE NEW YORK B. COUNTY Orange
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY Bear Mountain
29. OFFICIANT Hon. Gerald V. Ha~ TITLE County
NAME (PRINT) -
SIGNATURE ~ TIt! - n J / ~ DATE August
MAILING ADDRESS ~
10 Market Street ' Poughkeepsie,
STREET CITYfTOWN STATE
30. WITNESS TO CEREMONY
ST
I CERTIFY THAT I SOLEMNIZEO
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE ~
nnl-l.QR /11 lOR'
YEAR
MONTH
YEAR
ZIP
2004 10 04 2004
28. PLACE WHERE MARRIAGE OCCURRED
Judge
9, 2004
SIGNATURE