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:; I A II: UI- NI:W YURK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as 10 my righllo enter inlo the marri e s
,...--.:
21. SIGNATURE OF GROOM ~ ."
--
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage 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.
{ ~ } ::~~::}~CITY CLER~ . ~t.....:- 25. A~I:~LEMNI::~TNHPERIOD BEG~:AR
SEAL SIGNATURE ~ . DATE O':t11912DO
MAILING ADDRESS .
'-..,-I STR~ Middlebu&h Rd, \~~ Falls, ~TE 12590 ZIP 03 20 2
~~~R~:Ri~~~ 10~0~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 D RELIGIOUS 1 ~ CIVIL
DATE AND AT THE TIME AND , ,'..... .
PLACE INDICATED. .c;...., PM O~ 9 D OTHER, SPECIFY
COUNTY 0tItchess
CITYfTOWN Wappinger
~~J~~c~ 1368
~G~~J~R 19
1. A. FULL NAME
MID~ur PlatlRRENT SURNAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
067-34 7949
2. RESIDENCE A. . ~~TE) B. ~8&S
C. X~~CK ONE D CITY cvrOWN D VILLAGE
SPECIFY Wappinger
o STREET ADDRESS 12 Bowdoin lane
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES IYNO
Mom/~/y~
3. A. AGE 61
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Looksmith
B. TYPE OF INDUSTRY OR BUSINESS OWR Business
5. PLACE OF BIRTH ~m~y~M~ork
6. FATHER
A. NAME Meyer Platt
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ullian Binsbufg
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE :2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? Oa/"1 / """'"
MONTH DA'I'" ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D~S D NO
10. IF PREVIOUSLY DIVORCED OR ANNULlED, PROVIDE THE FOLLOWING INFORMA nON
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
0812112002 PGyghkeepsie, New Yark:
D
D
D
W
UJ
Z
W
o
:::J
29. OFFICIANT
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
Mn?fJ(cff)l.J (/1 \. )
STREET CITYfTOWN
30 WITNESS TO CEREMONY
NAME (PRINT) P,f;..,i s<!..; / I ~
SIGNATURE~ ~~
DOH.9S (11I9B)
~~
o:>>.I-\IC. rll..c. ,..umac.n
(THIS SPACE FOR STATE USE ONLY)
"~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
aa~ Jean MtCQlrtl'uRNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Larrabee
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER D7fi.-4B--S194
12. RESIDENCE A. N v B. n......h...."s
l(mTE) "'~
C. CHECK ONE D CITY D.;OWN D VILLAGE
AND \AI. .
SPECIFy.\<.Vapplnger
D. STREET ADDRESS 12 Bc1Mdoin Lane
13. A. AGE 46
14. EMPLOYMENT
ZIP 12590
YES eVNO
/1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
ca1/
M QI
13.B. DATE OF BIRTH
A. USUAL OCCUPATION L.ock&mith
B. TYPE OF INDUSTRY OR BUSINESS Platt's CouRtly Village
15.PLACEOFBIRTH ~~~fj)~
16. FATHER
A. NAME C'iUleton F, Larrabee
B. COUNTRY OF BIRTH U S ,4,
17. MOTHER
A. MAIDEN NAME PFiseilla M. TOFfElnee
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE :2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0 1
8. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D ~ATH
C. DATE LAST MARRIAGE ENDED? 03/ n1 / ..0A3
MONTH DAY YrP
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES [NItO
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
D
D
D
D
D
D
DATE 03l19J2004
by New York Domestic
MONTH
YEAR
05
18 2004
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTyf~,.q..vl
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF Jlf TOWN OF D VILLAGE OF
SPECIF~i(l- tlsn, I.(., ..v
NAME (PRINT)
SIGNATURE ~
