059
STATE OF NEW YORK I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutcbes'! DEPARTMENT OF HEALTH
CITYfTOWN Wappinger
~~J~~c~ 1368 AFFIDAVIT, LICENSE and
~5~~l~R 59 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME ~ M. Me "1fSURNAME 11. A. FULL NAME J . "liS.
FIRST FIRST RaI _. ~ENT SURNAME
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23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e of the 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 onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
TIME
06I15Q004 M
11''''''''
, A E ZP 'VUpM
27. TYPE OF CEREMONY
~ELlGIOUS
9 0 OTHER, SPECIFY
TITLE '1?~..~
DATE 6/1 ~ /0 <j
~~ --~ /f(. r /~
STATE ZIP
31. WITNESS "UREMONY_
NAME (PRINT)
SIGNATURE ~
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N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1QB..68..2986
2. RESIDENCEA.~)yQl:lc B. ~.I
C. CHECK ONE 0 CITY [inOWN 0 VILl.AGE
AND n ......tee .
SPECIFY rOl "21" p81e
D. STREET ADDRESS 15 BroacMew Road
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
M~ / 3.~
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3. A. AGE 27
4. EMPLOYMENT
A. USUAL OCCUPATION Landlcaping
B. TYPE OF INDUSTRY OR BUSINESS B & W Llncllcaplng
5. PLACEOFBIRTH~~~rk
6. FATHER
A. NAME Stev<<I Henry Me Mllllter
B. COUNTRY OF BIRTH USA
7. MOTHER
3B. DATE OF BIRTH
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A. MAIDEN NAME Jean Merl. Lee
B. COUNTRY OF BIRTH U 8 A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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 ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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{ SEAL }
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NAME (PRINT)
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
12603
YES CiI' NO
/ y1W6
DEATH
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(2) 0 DEATH
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~s~(Mr~~~~~e~~SE)M& Master
D. SOCIAL SECURITY NUMBER 073-72-9934
12. RESIDENCE A. NlIMl:ycnk B. ~I!
C. CHECK ONE 0 CITY Q#OWN 0 VILLAGE
AND n ......a.......-i
SPECIFY rOu.-.-.-.e
D. STREET ADDRESS 15 BroacMew Road
13. A. AGE 25
14. EMPLOYMENT
ZIP 12603
YES C4'NO
~ilB
E. IS RESIDENCE WITHIN LIMITS OF .cITY OR INCORPORATED VILLAGE? 0
Mo1r1 / 11
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Aa:ountaRt
B. TYPE OF INDUSTRY OR BUSINESS D' kOlRgtlo & Co.
15. PLACE OF BIRTH~~W.' YO*
16. FATHER
A. NAME stephen Foster
B. COUNTRY OF BIRTH U & A
17. MOTHER
A. MAIDEN NAME Jlnet Jones
B. COUNTRY OF BIRTH U S ^
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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o 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
o
o
by New York Domestic
MONTH
YEAR
MONTH
YEAR
08
16
08
14 2004
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY -P(/"rc./;~s.r
C. LOCATION OF CEREMONY
(CHECK ONE ~N~ SPECIFY)
o CITY OF K TOWN OF D VILLAGE OF
SPECIFY tJYII'J-t,)r , .'