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COUNTY Dutchess
CITY/TOWN Wappinger
~~~~~c~ 1368
~~~~J~R 13
STATE OF NEW YORK
DEPARTMENT OF HEALTH
::) I A 11::. f-ILt: NUMBE:H
(THIS SPACE FOR STA TE USE ONL Y)
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
f;Qward A GO~Qt:tT SURNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~a M. Ga~iNT SURNAME
1 A FULL NAME
11 A. FULL NAME
FIRST
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
069-6[)" 7608
B. QMt~~ess
VILLAGE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Garcia
C. S~~~~~JNfLT~~~t~~O~~SE) GotJgh
D. SOCIAL SECURITY NUMBER 098--68--5385
12. RESIDENCE A N(S'iTE) B. ~~esE
C. X~6CK ONE 0 CITY D..,OWN 0 VILLAGE
SPECIFY \Nappinger
o STREET ADDRESS 29 Baldwin Drive ZIP 12590
2 RESIDENCE A. ~ V
lSTJ.TEI
C X~6CK ONE 0 CITY o;rOWN 0
SPECIFY \f\lappinger
D. STREET ADDRESS 29 Baldvllin Drive
ZIP
12590
YES CV'NO
/y~1
13.8. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES CVNO
M~ / 1l /1~
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
/
MO..QP D1y1
13. A. AGE 35
14. EMPLOYMENT
3 A. AGE 42
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Electronics Technician
B. TYPE OF INDUSTRY OR BUSINESS Fryer Machine Co.
5. PLACE OF BIRTH ~D~~y~M;(orlc
6. FATHER
A. USUAL OCCUPATION Credit & Collections
B. TYPE OF INDUSTRY OR BUSINESS Combe Inc.
15 PLACE OF BIRTH ~9lN'~or~1c
16. FATHER
A. NAME Thomas Joseph Gough
B. COUNTRY OF BIRTH USA
7. MOTHER
A. NAME Luis Garcia
B. COUNTRY OF BIRTH Dominican Republic
17. MOTHER
A. MAIDEN NAME Marie Louise Corbat
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. MAIDEN NAME Felicia Morel
B. COUNTRY OF BIRTH Dominican Republic
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
o
(2) 0 DEATH
o
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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
w
en
z
w
()
::i
1 ST 0 0 1 ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that)o the best of rny kn071edg ,aM belief that the Information I provided IS true and that I declare that no legallmp~enl eXists
as to my nght to enter Into the mar~la . Ie ;" " C" (
, ,./ ~ '. , ~+'7./J .I '
21 SIGNATURE OF GROOM ~ ' '....~4T~r. <.,' 22 SIGNATURE OF BRIDE ~ ,- ,tfA,t?tf'.t(;( (/J/u-'t- e.~
~?E CUAAE AML - E CUR,~ENl NAME
23 SUBSCRIBED AND SWORN 1'b BEFORE ME, ' I /'
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 0310512004
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New 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
{ } NAME (PRINT~~' ~
SEAL SIGNATU;;~'" ~ DATE 03'0"000
MAILING ADDRESS t... " "
'-v-' STR~ Middlebblsh Rd, VVa~ Falls, ~TE 12590 ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY r/c
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND 011
PLACE INDICATED. Y 9 0 OTHER, SPECIFY
YEAR
MONTH
YEAR
TIME
MONTH
06
05
04 2004
03
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY \)utc.hts~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY Q " I
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)