No preview available
006 f- Z W (/) W lD o ...J :J o I (/) Z o ;:: <( II: f- (/) a W II: W CJ <( a: II: <( ::;; u. o W f- <( a u:: ;:: II: W a W II: W I ~ (/) (/) W II: o o <( >- u. <> W 0- (/) ~IATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM TJ'mglas E. G~ SURNAME COUNTY CITYfTOWN DISTRICT NUMBER REGISTER NUMBER Dutchess Wappinger 1368 6 :::tJAIt:. r-IL.I: NUMtSl:.H (THIS SPACE FOR STATE USE ONL Y) L 0 SUPPLEMENTAL FILE 1. A. FULL NAME FIRST 0- N B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER FROM THE BRIDE 11. A. FULL NAME FIRST J~ G. Rgg8~~TSURNAME B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT RogefBGA C. SURNAME AFTER MARRIAGE Gander (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER 144--62-B054 12. RESIDENCE A. ~si(TE) 8. Q~8SS C. CHECK ONE D CITY D ,,:JWN D VILLAGE AND 'A" . SPECIFY ti appll':'1ger D. STREET ADDRESS 19 Oord Drive 13. A. AGE 41 14. EMPLOYMENT ZIP 12590 YES Dw'No /1~ 099-40.&170 2. RESIDENCE A. Io.J v Bn.drh-s I~T.tTE) . t=ll1'm"J' .-- C. X~~CK ONE D CITY D.i'fOWN D VILLAGE SPECIFY Wappinger D. STREET ADDRESS 19 Dord Drive ZIP 12590 E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES Dfl'No MoNQ;2 / ~ / y1~ 3. A. AGE 51 4. EMPLOYMENT 3B. DATE OF BIRTH E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D / MOW ~ 13.B. DATE OF BIRTH A. USUAL OCCUPATION Administrativ.e Assistant B. TYPE OF INDUSTRY OR BUSINESS Unemployed 15. PLACE OF BIRTH (~~A.g[,,~~ Jersey 16. FATHER A. NAME .~vjn Reid Rogerson B. COUNTRY OF BIRTH USA 17. MOTHER A. MAIDEN NAME MeRica Elizabeth LYAOO B. COUNTRY OF BIRTH U 5; A 18. NUMBER OF THIS MARRIAGE 2 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT DEATH A. USUAL OCCUPATION Technical wnter B. TYPE OF INDUSTRY OR BUSINESS Entergy Nudear N E 5. PLACE OF BIRTH ~l!O~ ~9!K) 6. FATHER A. NAME Edward William Gander B. COUNTRY OF BIRTH USA 7. MOTHER A. MAIDEN NAME Rite ,. .AAe Eckert B. COUNTRY OF BIRTH U 5; A 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) D 'ltvORCE (3) D ANNULMENT (2) D DEATH C. DATE LAST MARRIAGE ENDED? 09/ 15 / 100A MONTH DA" Y~ D. ARE ANY FORMER SPOUSE(S) ALIVE? D ~S D 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 II: UJ lD ::;; :> Z o Z <( I- UJ UJ II: I- '" 23. SUBSCRIBED AND SWORN TO BEFORE ME SIGNATURE OF TOWN OR CITY CLERK ~ This license authorizes the marriage in New York State f 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. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS ~:i::i :Jt:Q 1-;';1- ~~~ I-WZ (/)...J::;; :JaW ~C}O f-Z(/) z- ~~~ tEaen 01->- w~~ b~~ Z::::i~ 1 0 0 B. HOW DID LAST MARRIAGE END? (3) D~VORCE (3) D ANNULMENT (2) D DEATH C. DATE LAST MARRIAGE ENDED? ' . W "3 / ?nn? MONTH DA"'" ~ D. ARE ANY FORMER SPOUSE(S) ALIVE? D ~S D 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 05lO3t2OO2 P.oughkeepsie, N&\~ York D'; D D D D D w UJ Z W () ::::i ~ { SEAL } '-.,,-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 INOICATED. 1ST 09115/1994 Middl.ex Co., N. J. 2ND 3RD D D D DATE 021131.2004 by New York Domestic TIME MONTH YEAR MONTH YEAR ZIP 13 2004 02 14 04 E 27. TYPE OF CEREMONY o D RELIGIOUS 9 D OTHER, SPECIFY l~CIVIL 28. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNTY (j L S,1i1 C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) D CITY OF KTOWN OF D VILLAGE OF SPECIFY II1IlRB L E. TO"O N TITLE (0 {/J NSlA S 1'( C E Z-1-q - 0+ Iv 1- 4-~ 3 NAME (PRINT) SIGNATURE ~