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STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY DI rtchesc;
CITYfTOWN Wappinger
~~~~~c~ 1368
~G~~J~R 2
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
"DUPLICATE"
1. A. FULL NAME
FROM THE GROOM
JMmP H. Thoml~T SURNAME
FIRST
8. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)
D SOCIAL SECURITY NUMBER 19.7.26--6540
2 RESIDENCE A. I\JV B n, It,..hess
. (SlATE) . (ro1'lmT1'
C. CHECK ONE 0 CITY [J,I'rOWN 0 VILLAGE
AND
SPECIFY Poughkeepsie
D. STREET ADDRESS 3 Richmond Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DY*iES 0 NO
3 A AGE 70 3B. DATE OF BIRTH MO~ / D1~ / y1~3
4. EMPLOYMENT
A USUAL OCCUPATION Retired
l-
S;
<(
c
u::
u.
" <(
;:
Q
B. TYPE OF INDUSTRY OR BUSINESS
5 PLACE OF BIRTH (~~Rao~~~~~fnia
6. FATHER
A NAME .4Jthur v.l. Thomley
B. COUNTRY OF BIRTH USA.
7. MOTHER
A MAIDEN NAME Isobel Rattray
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
001
B. HDW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 "I!I:ATH
C. DATE LAST MARRIAGE ENDED? OY ns / ?n03
MONTH DA1'" ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ~O
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
o 0
o 0
o 0
w
en
z
w
u
:J
~
{ SEAL }
'-v-'
29. OFFICIANT
NAME (PRINT)
SIGNATURE ~
ING Aro~SrJOU Y'"
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) P~+i,c. \ ,a..
SIGNATURE ~ fl2tJ;...i:.,U-
DOH.98 (11198)
M E:idle
In. ZLcIe ~
L D SUPPLEMENTAL FILE
.J
FROM THE BRIDE
11. A. FULLNAME FIRST M~ A. G~TSURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Me Gill
C SURNAME AFTER MARRIAGE Thomle\l
(OPTIONAL - SEE REVERSE) '7
D. SOCIAL SECURITY NUMBER Q46..28--5640
12 RESIDENCE A. I\J V B. n, It,..hess
"""STATE) ~
C CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND \AI .
SPECIFY vvappmger
D STREET ADDRESS 29 Brian Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Dw'No
MOQf$ / m /1~1
13.B. DATE OF BIRTH
13. A. AGE 72
14. EMPLOYMENT
A. USUAL OCCUPATION Retired
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~AX/PciJ&~~!Jl~~ York:
16. FATHER
A. NAME Char:les J Me Gill
B. COUNTRY OF BIRTH USA
17. MOTHER
A, MAIDEN NAME Colette PO'..l8rs
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0 1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 ~ATH
C, DATE LAST MARRIAGE ENDED? 07 / ~1 / 1Q93
MONTH DAY y't~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D..ro
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
1ST
2ND
3RD
o
o
o
o
o
o
DATE 01f3012OO4
by New York Domestic
TIME
MONTH
DAY
YEAR
MONTH
YEAR
ZIP
09:5~~
01
31
20
03
30 2004
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT,;DvtC.kt sS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
,l(i CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFyPCVj~l~.s\te .J
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) Ed vJ ~V' d A. E:.. / ell e-
SIGNATURE ~ Eel W"'ZLre>L .,4. 6~ ~