049
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Scott R. Leenig
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Marissa L Stevenson
11. A. FULL NAME
1. .A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
FIRST
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N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Leenig
(OPTIONAL - SEE REVERSE) 078-68-9966
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
. (STATE) ~ (COUNTY)
C. CHECK Oti,E. . [J CITY 0 TOWN D VILLAGE
~~CIFY waPPInger
D. STREET ADDRESS 1 ~ t;)Chuele Dr1\Ie
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 045-76-1515
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) .I (COUNTY)
C. CHECK ONE D CITY D TOWN J::J VILLAGE
. ~~~CIFY Wappingers Falls
D. STREET ADDRESS 2764 west Main st. Apt.:3 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r! YES 0 NO
3. A. AGE 27 3B. DATE OF BIRTH 07 /26 /1976
MONTH DAY YEAR
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, r
ZIP 12590
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YE~.Q", NO
13. A. AGE 24 13.B. DATE OF BIRTH 11 /23 ~S
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Bartenderl Driving Instructor I ,
B. . TYPE OF INDU~TflY ORJ~US~fiES!i HOIlaay Inn & BrOYRl s D. .
15. PLACE OF BIRTH NfIN Kocnelle, NeW York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Gerald Edward stevenson
B. COUNTRY OF BIRTH U ::) A
4. EMPLOYMENT
A. USUAL OCCUPATION Carpenter
B. TYPE OF INDUSTRY OR BUSINESS self - Employed
5. PLACE OF BIRTH Carmel, NfIN York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert James Leenig
B. COUNTRY~F BIRTH USA
7. MOTHER
A. MAIDEN NAME Elizabeth Ann Macken
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOOCE CIVIL ANN~LMENT
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17. MOTHER
A. MAIDEN NAME Carol Ann Di Chiaro
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV6RCE CIVIL AN~LMENT
DE'l:)H
De.aoH
(2) D DEATH
(3) D ANNULMENT
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) D DEATH
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY 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
MONTH DAV YEAR
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
D
D
D
1ST
2ND
3RD
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22. SIGNATURE OF BRIDE ~
21. SIGNATURE OF GROOM
23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CITY CLERK DATE
This license authorizes the marriage in New York S and groom named above by any 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.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY ~LEF!K J M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glona . orse
{ 05f27 TIME MONTH
SEAL SIGNATURE ~ _ . (l TE
'-y-I MAI~Mr&bush R Falls, NY 12590 02:21~~ 05
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27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY t>u:\cnl9.
c. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
D CITY OF ~TOWN OF D. VILLAGE QF
SPECIFY 'p;Mr f;s IJ-JCIL l...
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