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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c~ 1388
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MlfL~C L KirscJJRRENT SURNAME
FIRST
(THIS SPACE FOR STATE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. FULL NAME
11. A. FULL NAME
Cmie/t GiragRENT SURNAME
FIRST
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~(M~~~~t~~e~~SE)KiI8Ch
D. SOCIAL SECURITY NUMBER 119-74-3862
12. RESIDENCEA. N_EYorlc B ~
C. CHECK ONE 0 CITY O"","OWN 0 VILLAGE
AND \At .
SPECIFY nllpplnger
o STREET ADDRESS 127 Cider Mill Loop ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
McOa / ~
YES W NO
~m
091.56-1287
2. RESIDENCE A. "'m.'*:)V QrI( 8 ~ess
C CHECK ONE 0 CITY CVTOWN 0 VILLAGE
AND
SPECIFY WAppinger
D. STREET ADDRESS 3 ~uga Driv8 ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MO~ / l'
125iO
12590
YES iY NO
/ y1&73
13. A. AGE 26
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
8. TYPE OF INDUSTRY OR BUSINESS Wapp. Cntrl. Sen. DIst
15. PLACE OF BIRTH ~I~U~N~.
16. FATHER
13.B. DATE OF BIRTH
3. A. AGE 31
38. DATE OF BIRTH
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4. EMPLOYMENT
A USUAL OCCUPATION TP.ler.nmmlJni~nrKl.
B. TYPE OF INDUSTRY OR BUSINESS Bridgecom
5. PLACE OF BIRTH ~-fI'ffiICO~ftWF '!~)
6. FATHER
A. NAME I ennArd n Kirsch
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Gloria Gibson
B. COUNTRY OF BIRTH Unltecl Kingdom
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
o 0
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
A. NAME Fl1Ink Anthony Gil1lrdi
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Margaret Ann V/lftne
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
DEATH
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
MONTH 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 ISSUEO AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, deposB and say, that to the best of my knowledge and belief that the information I provided is trU(1nd that I declare that no legal Impediment exists
as to my nght to enter Into the marnage e., . a ~
21 SIGNATURE OF GROOM ~ SIGNATURE OF BRIDE ~ 01 AD #0 ....d. '
USE CURRENT NAM -.;
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 06124/.2004
This license authorizes the marriage in New York St 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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NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DAY
AM
PM
08
23 2004
08
25
ZIP
ATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN 'OF ri VILLAGE OF
SPECIFY'W Q...ff\V\7J.sa.rs. l=o...J..l.>
29. OFFICIANT 7vl.... J..+
NAME (PRINT) TITLE -"
SIGNATURE ~ DATE ? 11'l,/d,t!
MAILING ADDRESS '7
S~~EET tH",.k:.V\ ~~ITYfTOW~pp1~ Fcu.1t, "?,.t~ J ~S ~ t)
3D. WITNESS TO CEREMONY ( 31. WITNESS TO CE
NAME (PRINT) ~ th~i's+ NJA ~ ~; y- a.Y-~1
SIGNATURE~~~_~~ 1
DOH-9B (11/98)
NAME (PRINT)
SIGNATURE ~
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