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009 I , ~:i::i ::leQ >-~>- ~~~ >-WZ UL..J ::; ::lUW ::;,,5 !z~cn G~~ ltocn 0>-> Ui~(3 b~\n Z:::i~ ] I I / STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM f-IowsIrd 0 Gill MIDDLE CU~NT SURNAME COUNTY Dutehess CI1YITOWN Wappinger D'h'iRICT 1~ NUMBER ~5~~J~R 9 1. A. FUll NAME RRST 0- N B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER Q69.66.A519 2. RESIDENCEA. "fmlYork B.~ C. CHECK ONE 0 CITY OII'rOWN 0 VilLAGE AND SPECIFY VVSlppiFlgP-r D. STREET ADDRESS 11G AJrAne Dd.ve ZIP 12590 E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES Cll"NO 3. A. AGE 38 3B. DATE OF BIRTH MOJP / Z1 / Y~ 4. EMPLOYMENT A. USUAL OCCUPATION MaintenatlCe B. TYPE OF INDUSTRY OR BUSINESS Self - Employ~ 5. PLACEOFBIRTH~X9fk 6. FATHER A. NAME George H. Gilleo B. COUNTRY OF BIRTH USA 7. MOTHER A. MAIDEN NAME Renll Appel B. COUNTRY OF BIRTH U S ^ B. NUMBER OF THIS MARRIAGE 1" 9. 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? o (2) 0 DEATH (3) 0 ANNULMENT / / 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 .;)."'..: rl~~ I.umg~n (THIS SPACE FOR STATE USE ONL Y) L 0 SUPPLEMENTAL FILE FROM THE BRIDE ~a Nichol_NT SURNAME ~ 11. A. FULL NAME FIRST B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT c. S~S~~~N~~~~~t~~e~~SE) Gillem D. SOCIAL SECURITY NUMBER 122-5C)..7490 12. RESIDENCEA. ~Erark B. Q~.I C. CHECK ONE 0 CITY D.,oWN 0 VILLAGE AND Wa . SPECIFY ppnger D. STREET ADDRESS HG Alpine Drive ZIP 12590 E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES o.INo MO~ / 11 /1$159 13. A. AGE 44 14. EMPLOYMENT 13.B. DATE OF BIRTH A. USUAL OCCUPATION Secretary B. TYPE OF INDUSTRY OR BUSINESS 'Nest. cty. Prob. 15. PLACE OF BIRTH ~~~ ~l?r:k 16. FATHER A. NAME '.l\Alliam NiGhglBOA B. COUNTRY OF BIRTH U 8 ^ 17. MOTHER A. MAIDEN NAME . 0101 Zacchl B. COUNTRY OF BIRTH U S ^ 1B. NUMBER OF THIS MARRIAGE 2 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT DEATH 1 0 0 B. HOW DID LAST MARRIAGE END? (3) D~ORCE (3) 0 ANNULMENT (2) 0 DEATH C. DATE LAST MARRIAGE ENDED? 04 04 / 04"\ / ""'^^'" MONTH" DA1:i:; ~ D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 lIES 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 11/1212002 Poughkeepele. New York a: w lD ::; ::l Z o Z <( tu w a: >- w 1ST 2ND 3RD 4TH I, being duly swom, depose and say, as to my right to enter into the ma. e 21. SIGNATURE OF GROOM ~ o o o o 1ST o 2ND o 3RD o 4TH and belief that the information I provided is true 23. SUBSCRIBED AND SWORN TO BEFORE ME SIGNATURE OF TOWN OR CITY CLERK ~ This license authorizes the marriage in New York S te of Relations Law lj11 to perform marriage ceremonies wit 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 Dr subsequent ceremony. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS w en z w o ::::i ~ { SEAL } '-..t-/ NAME (PRINT) SIGNATURE ~ - MAILING ADDRESS 22. SIGNATURE OF BRIDE ~ by New York Domestic TIME MONTH 25. B. 80LEMNlZATlONPERIOD ENDS AT MIDNIGHT ON: YEAR MONTH DAY YEAR TE 09:~~ 02 25 04 24 2004 2B. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNr:L'hl~k( C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF )(TOWN OF 0 VILLAGE OF SPECIFYL~ft' ~f' ,-- 8m I CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF THE PER- SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND PLACE INDICATED. TE 27. TYPE OF CEREMONY o 0 RELIGIOUS 9 0 OTHER, SPECIFY ZIP 1~ 29. OFFICIANT NAME (PRINT) ~IC'P