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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MllRdd J. P8l!JlENT SURNAME
::I COUNTY
CITY/TOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Outeh8SS
~Pringer
1368
12
1. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURllY NUMBER
2. RESIDENCE A.
12.s.&2 ]273
r,I. Yor:Ic B. (DWw:-s
C. ~~6CK ONE 0 CITY o.,rOWN 0 VILLAGE
SPECIFY Wappinger
D. STREET ADDRESS 740 Old Route ~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3B. DATE OF BIRTH
ZIP
3. A. AGE 32
4. EMPLOYMENT
A. USUAL OCCUPATION GSRSFBt9r TeshRieiflR
B. TYPE OF INDUSTRY OR BUSINESS Cwmmlns Metre PGI:l8r
5. PLACE OF BIRTH ~t~)
6. FATHER
M
A. NAME Robert F. P8teFs
B. COUNTRY OF BIRTH U I A
7. MOTHER
A. MAIDEN NAME Muriel R. roumler
B. COUNTRY OF BIRTH US!'.
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 g 0
B. HOW DID LAST MARRIAGE END? (3) DIJIIlIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? -- / 1'18 /. """"1
M~ ~ DA~' ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D#S 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
1 ST 02lO8l2OO1 Mt. Holey, New Jersey
2ND
3RD
4TH
I, being duly swom, depose and say, that to the be
as to my right to enter into the .
21. SIGNATURE OF GROOM ~
o
o
o
DIIIf'
o
o
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Pt4i;bd& Cl:JmrmiOAT SURNAME
-1
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~S~~JN~~~~~t~~e~~SE) Pdcrs
D. SOCIAL SECURllY NUMBER Q95..1Q..9029
12. RESIDENCE A. "'jYork B. ~ess
c. ~~6CK ONE 0 CITY 0 JDWN 0 VILLAGE
SPECIFY V/appinger
D. STREET ADDRESS 7>40 Old Route 9 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D,.,tlO
13. A. AGE 33 13.B. DATE OF BIRTH MONtG / . / 1WO
14. EMPLOYMENT
A. USUAL OCCUPATION TrUe Closer
B. TYPE OF INDUSTRY OR BUSINESS Regency Abstract
15. PLACE OF BIRTH (iY........,H.VoVtOd<
16. FATHER
A. NAME Richard Chartes Cumming
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jb Mhe b:;rll~
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
. A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
. DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
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
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized
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)
SIGNATURE ~
MAILING ADDRESS
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
YEAR
TE
ZI
AM
11 :O$M
c<O 0'-(
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
!t<l/'l1 ~ (~
,):30
~~~:f~1I~ G t\-I ~ Pr ~OH t.fJ- T"-{ TITLE ~Wl.,-:r usi-i t.-e..
SIG.NATURE~ Po ex"" \.f ~~aho~~ ~
MAILING ADDRESS P -U1lj . '" 0
l'7E.cc ~ L, I oL,..\ 3 1
,
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
.5
CITYfTOWN
NAME (PRINT)
SIGNATURE ~
DOH-9a (11I9B)
STATE
1 pi CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY ..5 fJ -e.(U) I o..:fo r
NAME (PRINT)
SIGNATURE ~