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STATE OF NEW YORK I STATE FILE NUMBER "I
COUNTY ~ (THIS SPACE FOR STATE USE ONLY)
CITYfTOWN Wappinger DEPARTMENT OF HEALTH
, ~~J~~1J 1368 AFFIDAVIT, LICENSE and
~5~I~J~R 88 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE -.l
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Gregory D. FtMon 11. A. FULL NAME u~ S. Marleau
ARST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME, IF OIFFEREtfT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 08"7 ~--D187
D. SOCIAL SECURITY NUMBER "-'~-U
2. RESIDENCE A. New York
(STATE)
C. CHECK ONE D CITY [Jl"-rOWN
~~~CIFY Marlboro
D. STREET ADDRESS 137 Western Avenue ZIP 12542
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES r!I NO
D6 / 17 / 1981
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE FIMon
D. SJ~I~~I~~~Ri::u~~~~RSE) 081-78-0827
12. RESIDENCE A. NP-wYork B. lJk&ter
. -(!iAtE) ~
C. CHECK ONE D CITY [JIlIII-OWN D VILLAGE
~~~CIFY Marlboro
D. STREET ADDRESS 137 Western Avenue ZIP 12542
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES cI NO
13. A. AGE 21 13.B. DATE OF BIRTH 1? . / n? AQR?
MONTH DAY YEAR
B. Ulster
(COUNTY)
D VILLAGE
3. A. AGE 23
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION HoI.Bekeeper
B. TYPE OF INDUSTRY OR BUSINESS The RIver Church
15. PLACE OF BIRTH New Hartford. New York
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Receiver
B. TYPE OF INDUSTRY OR BUSINESS L.owIs Home Center Inc.
5. PLACE OF BIRTH PftutJhIMAMl.. New York
~FNOTUSA)
6. FATHER
A. NAME Curtis SvenFulton
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Unda SUe Du BaI!l
B. COUNTRY OF BIRTH U SA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
16. FATHER
A. NAME Jeffrey T. Marleau
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME BArhRrA A. NAIMn
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
0, 0
DEATH
o
(2) D DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
D D
D D
D D
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? D YES D 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
D
D
D
w
en
z
w
o
::i
by New York Domestic
TIME
MONTH
YEAR
ATE Cf1.
ails NY 12590
TATE
27. TYPE OF CEREMONY
o B"RELlGIOUS
9 D OTHER, SPECIFY
11:1&M
PM
07
ZIP
STRE
I CERTIFY THAT I SOLEMNIZED
THE. MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORKe. COUNTYQU7tJt~~)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY OF D TOWN OF D' VILLAGE OF
SPECIFY p~
1 D CIVIL
iil~l~o:m M ftRl. 0 q) CO JS, U IJ H )If V4
SIGNATURE ~ fYJ o.J.ow AL ~
M~~NGXRj~k ~~
STREET CITYfTOWN
30. WITNESS TO CEREMONY
NAME (PRINT) (;-~.AN'" ~ 1- j'"O-r\.
SIGNATURE~ ~ - --'
-
~
DATE f- ~- () y
YI~ IUol
SATE
TITLE
NAME (PRINT)
SIGNATURE ~
nnl-4_0A 1111OA\