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COUNTY
CITYITOwN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gary P. Hays, III
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
DutchesS
::pt;Anger
1
47
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Michelle L Gordon
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
o
CJIj
Ul
N
....
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 456-73-2900
D. SOCIAL SECURITY NUMBER
New York
(STATE) oil
C. CHECK ONE 0 CITY 0 TOWN
~~~CIFY Wa. r
U
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hays
(OPTIONAL. SEE REVERSE) 006-86-3324
D. SOCIAL SECURITY NUMBER
New York: B Dutchess
(STATE) oil' (COUNTY)
C. CHECK ONE _ R Cln: 0 TOWlII 0 VILLAGE
~~~CIFY wappinger
21 surrey Lane ~ F ZIP
2. RESIDENCE A.
B. Dutchess
(COUNTY)
o VILLAGE
12. RESIDENCE A.
12080
o YES 0 NO';
Q9/ 1971
D. STREET ADDRESS
D. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
. A. AGE 25 13.B. DATE OF BIRTH Q7
DAY
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 26 3B. DATE OF BIRTH 10
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Benefits Manager
B. TYPE OF INDUSTRY OR BUSINESS HItaChI MellIS
15. PLACE OF BIRTH NewburQh, New York
(CITY, STATE/COUNTRY IF NOT USA)
Student
Duteness comm. COIl
exas
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Dallas Cou ·
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
Paul Gordon
USA
6. FATHER
A. NAME Gary Pal ~ Jr.
B. COUNTR~ OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
Sharon Brown
USA
1
B. COUNTRY OF BIRTH
Jannette Thompson
Germany
1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULME!il"
,0 U
DEATH
o
DEATH
B. HOW DID LAST MAJl81AGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID i..AST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose an
as to my right to enter into the
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
say, that t the best of my knowledge and belief that the information I prOVided is true and that I declare that no legal impediment exists
iage stat. Jrh':L ~ I n It,d.J..
SIGNATURE OF BRIDE ~ .:~_~.J..!!J&IIlJ.U'- a~
USE CURRENT NAME
OS/21J2004
DATE
the bride and groom named above by any person authorized by New York Domestic
York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
IME
MONTH
~
{ SEAL }
'-..t-I
NAME (PRINT)
_ TE OS/21
Falls NY 12590
ZIP
SIGNATURE ~-
MAILING ~tildcl
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
0..
/TOWN TATE
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 \tRELlGIOUS
10'.." 0 AM IJb I" J./Jo'f 9 0 OTHER, SPECIFY ,
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ORfil11r;,E..
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
,lS(CITY OF 0 TOWN OF [j VILLAGE OF
SPECIFY Newbulu; H.
.
e.HLM~HOF tll e GooD 6~E'p)-l~
.10 CIVIL
29. OFFICIANT cE.d M ~ ~ J 1) G"Su E"'" A
NAME (PRINT) .... Ol <..J'\
SIGNATURE ~ ~
MAILING ADDRESS ~'V /(Jc
!.s, Bo~ :t9,-S,~::~~ h,
30. WITNESS TO CEREMONY
E".,.
TITLE' h 1;; ~"It. '1>1Z.
DATE ~tf~~ 19, 2-00 t-/
N , 't, J :2.55"0
S ATE ZIP
31. WITNESS TO CEREMONY
L
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
SIGNATURE ~
"'I"'\U 1"\0 I~ ~ InO'