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STATE OF NEW YORK I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dt dchess DEPARTMENT OF HEALTH
CITYfTOWN Y\lappinger
~~J~~W 1368 AFFIDAVIT, LICENSE and
~5~~l~R 50 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME JI~ R. BiMtENT SURNAME 11. .A. FULL NAME ~ N. NetllCmENT SURNAME
FIRST FIRST
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N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 134 5Or~~13
2. RESIDENCE A. ~_ffQr:k B. ~ess
C. CHECK ONE 0 CITY 0 TOWN ~VILlAGE
AND 'AI .
SPECIFY nllPPlRQe18 FlIIls
D. STREET ADDRESS 56 South Remsen Avenue ZIP 12580
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? Q;YES 0 NO
M0A2 / 28 / 4B59
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Baer
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 14s..~ 1254
12. RESIDENCE A. ~ B. ..1.- -. · l.wen
1wf~T A TE) r"""..1 r J aw
C. GJ5CK ONE 0 CITY []"IOWN 0 VILlAGE
SPECIFY V'Jesl Haven
D. STREET ADDRESS 10 ~18A Street ZIP 08S18
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES q; NO
M_ ./>> "1981
3. A. AGE 4S
4. EMPLOYMENT
3B. DATE OF BIRTH
13. A. AGE "Jl
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Health Physics
B. TYPE OF INDUSTRY OR BUSINESS EAtera'
5. PlACE OF BIRTH ~~ NIw~onc
B. FATHER
A. USUAL OCCUPATION 8tfiIff Aceountant
B. TYPE OF INDUSTRY OR BUSINESS Westpolt ~ OInk
15. PlACE OF BIRTH _~Wll!lltslftd.
16. FATHER
A. NAME Richar S....
B. COUNTRY,OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Judth Nelffer
B. COUNTRY OF BIRTH U S ^
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME MauFiee Nelsan
B. COUNTRY OF BIRTH Jamaica
17. MOTHER
A. MAIDEN NAME
'Berferty WebbeI
B. COUNTRY OF BIRTH Jemllca
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
1 0 0
B. HOW DID LAST MARR~GE END? (3) CiIItIIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE lAST MARRIAGE ENDED? MONTH 05 / olJ7 / _~
D. ARE ANY FORMER SPOUSE(S) ALIVE? [J,II'ES 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
o. 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE lAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
MONTH OA Y 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
1ST 05J07/200~ Peughkeepsle, Ne~:JYork D; 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly swam, depose and say, that to the best of my knowledge and belief that the information I provided is true all
as to my right to enter into the marriage t e. .
o
'0
o
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Sta person 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
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
AM
10:12pM 08 02 07 31 2004
28. PlACE WHERE MARRIAGE OCCURRED
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
, AT
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
26. SOLEMNIZATION OCCURRED
TIME. M. DAY YEAR
330 AM Or I ()~I ~
~.~"~m~..J B~..AR
NAME (PRINT) rVl. fJ
~. . . i;)
SIGNATURE ~ .
MAILING .wDRES~ _ /J . / . //
111 'G't:S7'A~ Ci~ 't!teS~Y'I7'"
STREET CITYfTOWN
30. WITNESS TO CEREMONY
10 CIVIL
A. STATE NEW YORK B. COUNTY (!/.., ","t'otJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF D. VILlAGE OF
SPECIFY H...A-tTS BuRf::rIJ
TITLE
'RevGlZe/'IO
o/'';~
DATE
;.2944
NAME (PRINT)
SIGNATURE~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~