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COUNTY Dutchess
CITY/TOWN V\lapplnger
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~~~I~J~R 53
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FiLl:' NUMtst:.H
(THIS SPACE FOR STATE USE ONL Y)
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NE'V Et€.
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l_ D SUPPLEMENTAL FILE
FROM THE BRIDE
11 A FULL NAME Gi I Hdli~
FIRST ~D'tI;' - --- CURRENT SURNAME
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT HoUi~
C. SURNAME AFTER MARRIAGE UUnIWII
(OPTIONAL. SEE REVERS~
D. SOCIAL SECURITY NUMBER 059-4&-4845
12. RESIDENCE A. N 'tTATE) B. ~
C. CHECK ONE D CITY [jtTOWN D VILLAGE
AND n... ......~
SPECIFY "'''''v ___y-u
D. STREET ADDRESS 120 Channingville Roact ZIP 12590
E. IS RESIDENCE WITHiN U"lITSOFCITY OR INCORPORATED VILLAGE? DYES rtJ NO
13. A. AGE 49 13.B. DATE OF BIRTH lIH /2Qy 1~
1. A FULL NAME
~ R. MLII1I"!lLENT SURNAME
FIRST
a.
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 134-62-7479
2 RESIDENCE A. N ~ATE) B. ~I
C CHECK ONE D CITY fI TOWN D VILLAGE
AND n...... .
SPECIFY ...Ot~
o STREET ADDRESS 170 Chsmnirvrille ROBd, ZIP 1~
E. IS RESIDENCE WITHiN UMITSOF CITY OR INCORPORATED VILLAGE? D YES ~ NO
3 A AGE 40 38 DATE OF BIRTH ~ / ~ / 111i3
4. EMPLOYMENT
A. USUAL OCCUPATION CarpenJer
8 TYPE OF INDUSTRY OR BUSINESS SeIf~ed
5. PLACE OF BIRTH ~;tork
6. FATHER
A NAME ~e MM....... .k'
8 COUNTRY OF BIRTH USA .
7. MOTHER
A. MAIDEN NAME &lei.. J. Plummer
B. COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATION ~ered Nume
8 TYPE OF INDUSTRY OR BUSINESS H V ~AhAb
15. PLACE OF BIRTH ~s~a, '.SA)
16. FATHER
A NAME R()hArt ~ ....,.~
B. COUNTRY OF BIRTH U S p..
17. MOTHER
A MAIDEN NAME M8d~ Joenne Burger
8 COUNTRY OF BIRTH II S A
lB. NUMBER OF THIS MARRIAGE ~
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 11 / ?003
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
1ST D D 1ST 11/24/1997 Pnl~. t\I Y aI [I
2ND D D 2ND 08I11nI'VR nlltdt R!It r.nlJnty, NY D r"f
3RD D D 3RD D CJ
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 mar' e state_ - / . /
21 SIGNATURE OF GROOM ~ 22 SIGNATURE OF BRIDEQ. l/ /c X.I U,/ ! / --i.J .'-.7.'
, ' U' \ / US~iU~RENT NAME U
SUBSCRIBED ANp SWORN TO BEFORE ME ~1rr7..-vv\A
SIGNATURE'OF.-,l'QWN9RCITYCLERK~ . DATE ~~
This lie . se authorizes ttle...-marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
RetG\!ions Law ~11 to perform r,narriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
_, D 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
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
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,
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B. HOW DID LAST MARRIAGE END?
(3) D DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH OA Y
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
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U...J " SEAL "-~'IGN~TURE ~ '
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".;T TREET ~.
I CJORtlFY THAT I SOLEI,INrtED
THE M'ARRIAGE OF TfiE' PER.
SONS NAMEQ, .ABOVE Of'! T.H, E
OATE AND "ATiTHE TiMe AND
PLACE INDICATED. ' ,
TIME
MONTH
YEAR
AM
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28. PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
A STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF D VILLAGE OF
o D RELIGIOUS
OTHER, SPECIFY
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29. OFFICIANT
NAME (PRINT)
TITLE
DATE
SIGNATURE ~
MAILING ADDRESS
SPECIFY
STREET
30. WITNESS TO CEREMONY
CITY/TOWN
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~