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~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
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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
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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
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{ 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 ~
