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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ro~J9hn C04.W~ SURNAME
1ST 0313112003 Goshen, New York D 1M" 1ST D D
2ND D D 2ND D D
3RD D D 3RD D D
4TH D D 4TH D D
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the ma 'agestate. . ~ '~.
21.SIGNATUREOFGROOM~ 22.SIGNATf.lREOFBRIDE~ ~_~
23. USE CUR NAME .
DATE 7/fJ
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
RelatiDns Law ~11 tD perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only fDr the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY Dutch@S$
CITYfTOWN \JVappinger
~~J~~c'{ 1368
~5~I~J~R 71
1. A. FULL NAME
FIRST
0-
N
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 05Q.- 72 7551
2. RESIDENCE A. N V 8. n. .......,OOC!
(mATE) ~
C. CHECK ONE D CITY III TOWN D VILLAGE
AND '^"'" .
SPECIFY \I .HIIppmger
D. STREET ADDRESS 30 Top 0 · Hill Road ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VIUAGE? D YES ~ NO
M~ / Qa, / 1370
3. A. AGE 33
4. EMPLOYMENT
38. DATE OF BIRTH
A. USUAL OCCUPATION Cert Athletic Trainer
B. TYPE OF INDUSTRY OR BUSINESS Peale Ph~ical Therapy
5. PLACE OF BIRTH ~Yw
6. FATHER
A. NAME Robert Joseph Coudrey
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy Lee TImme!
B. COUNTRY OF BIRTH U S ,11,
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) M' DIVORCE (3) D ANNULMENT
C. DATE LAST MARRIAGE ENDED? MONTH03 / D~1
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
1
o
(2) D DEATH
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::iIAI~ t'ILt:. NUMtsl::.H
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jc~umpr Lynn ~~ENT SURNAME
~
11. A. FULL NAME
FIRST
S. BIRTH NAME (MAIDEN NAME), IF DIFFERENT King
c. SURNAME AFTER MARRIAGE "oudrcv
(OPTIONAL. SEE REVERS!"Y ;T
o SOCIAL SECURITY NUMBER 055 60 1232
12. RESIDENCE A. N ~TATEI B. D~
C. ~~6CK ONE D CITY ~ TOWN D VILLAGE
SPECIFY \.^!appinger
D STREET ADDRESS 30 Top O' Hill Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE? DYES Iiit NO
JJBH /11lv {9(~
13. A. AGE 2~
14. EMPLOYMENT
13.8. DATE OF BIRTH
A. USUAL OCCUPATION Physical Ther-apist
B. TYPE OF INDUSTRY OR BUSINESS Peak Physical Thera~
15. PLACE OF BIRTH tcIJ~~HN't~t~
16. FATHER
A. NAME \.^Alliam King
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Mary Me Lees
B. COUNTRY OF BIRTH USA
1 B. 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) D DIVORCE
(3) D ANNULMENT
/ /
o
(2) D DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH OA Y YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
w
en
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{ SEAL}
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MONTH
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
MONTH
DAY
YEAR
ZIP
07
30 2004
02
2004 08
TAT
27. TYPE OF CEREMONY
O)?"RELlGIOUS
9 D OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
2B. PLACE WHERE MARRIAGE OCCURRED
1 D CIViL
Uf-ft fJ q e..
rp a...::;.,- () R-
7..~::3-01
A. STATE NEW YORK 8. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ,!)i(i'OWN OF VILLAGE OF
SPECIFY lJ. J CJ /') 11:1 e. iA R.. J I rV l.j
STATE
E.
NAME (PRINT)
SIGNATURE ~