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~. CITYfTOW.N Wappinger
DISTRICT 1368
- NUMBER
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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.~WtIW J. C4WNT SURNAME
I
!;IAII: ~ILI: NUMIlI:H
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
MtfiWlRn S81'-\'a~., SURNAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Z8fv8B
C. S~~~ur~~rt~~~~~SE) CcIIfey
D. SOCIAL SECURITY NUMBER Q59 SQ'/52fi9
12. RESIDENCEA. ~rcaFk B. ~BBI
C. CHECK ONE 0 CITY O-'OWN 0 VILLAGE
AND lA .
SPECIFYvJappnger
D. STREET ADDRESS 30 HI 'AM Road ZIP 12580
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D;NO
MJIi / G3 ~9&5
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER oss.-5S-01 ~
2. RESIDENCEA. _IYcark B. ~'IBI
C. CHECK ONE 0 CITY Qll'OWN 0 VILLAGE
AND lAM.
SPECIFY v-AlAgeI'
D. STREET ADDRESS 30 H View RoId
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3B. DATE OF BIRTH
ZIP
13. A. AGE 38
14. EMPLOYMENT
13.B. DATE OF BIRTH
3. A. AGE 44
4. EMPLOYMENT
A. USUAL OCCUPATION 1he8t Metal '.~
B. TYPE OF INDUSTRY OR BUSINESS IiImsforcl Sheet Metal
5. PLACE OF BIRTH ~~YA..)
6. FATHER
A. USUAL OCCUPATION OBmeBtls Engineer
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~1\.~~pFk
16. FATHER
A. NAME Jllhn SimCIR ~..
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mlryl"" Potueek
B. COUNTRY OF BIRTH U 8 ."-
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. NAME ._____ Jam. CaIfey
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME DerIs Marie Ahem
B. COUNTRY OF BIRTH U' A
B. NUMBER OF THIS' MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) O~VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / "^ / "'VV'tI\
MONTH . D-,,;w if!!i!!IIlI'V
D. ARE ANY FORMER SPOUSE(S) ALIVE? O~S 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
100
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? oe/ M / 'Vtt'I')
MONTH DA"-' ...-
D. ARE ANY FORMER SPOUSE(S) ALIVE? ollll'Es 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
a:
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o 1ST 0412012QOQ JamalG8. NewYGFk 0-" 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
lie t at the information I provi ed IS true and that I declare that no legal impediment exists
2 SIGNATURE OF BRIDE ~ ~~ Cr- ~~ t'\J ~ ~
~SE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 0912612OO3
This license authorizes the marriage in New York St the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
. 0 If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
1ST QW05I2OCQ QOIhIR. *"V York
2ND
3RD
4TH
I, being duly sworn, epose and say, that t th
as to my right to enter into the marriage e.
21. SIGNATURE OF GROOM ~
w
en
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o
::J
YEAR
MONTH
YEAF
~
{ } NAME (PRINT)
SEAL SIGNATURE~-
MAILING ADDRESS
'-.t-I .
S R
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
25 2003
09
27
11
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF
29. OFFICIANT
NAME (PRINT)
SPECIFY