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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
ClvilfwJher M. ~_~RNAME
FIRST
COUNTY Dut.dless
CITY/TO~N Wappinger
DISTRICT
.lUMBER ~ 388
'REGISTER
NUMBER 100
::SIAI~ "'IL~ NUMI:S~H
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
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1. A. FULL NAME
11. A. FULL NAME
bll(pn Jo MiII.RRENT SURNAME
FIRST
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE .a. pi
. (OPTIONAL - SEE REVERSEJ"ft"'m e
D. SOCIAL SECURITY NUMBER Q89.68..2661
12. RESIDENCE A. N_Nork B. QutIlh,ess
C. ~5CK ONE 0 CITY q,OWN 0 VILLAGE
SPECIFY l"aughke&pBi&
D. STREET ADDRESS 18 Peeeoek Lan. ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF cnv OR INCORPORATED VILLAGE? 0 YES q" NO
MIM /a ~m
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER Q65.. 70...5666
2. RESIDENCE A. ~~BFk B. ~eBB
C. ~~~CK ONE 0 CITY ~TOWN 0 VILLAGE
SPECIFY Paughk8epBie
D. STREET ADDRESS 18 PeaGOOlc lAne ZIP 12801
E. IS RESIDENCE WITHIN LIMITS OF cnv OR INCORPORATED VILlLAGE? 0 YES ~ NO
3. A. AGE 30 3B. DATE OF BIRTH MOIS / 28 / .;UJl3
4. EMPLOYMENT
A. USUAL OCCUPATION Ii. M. s.
B. TYPEOF INDUSTRY OR BUSINESS Allme E. M. S.
5. PLACE OF BIRTH -i~,,"~..NMte Rlee
6. FATHER
A. USUAL OCCUPATION DiBpBtcher
B. TYPE OF INDUSTRY OR BUSINESS Out Ctf. Sherttr's OffIce
15. PLACE OF BIRTH ~...._.__; York
16. FATHER
13. A. AGE 26
14. EMPLOYMENT
13.B. DATE OF BIRTH
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A. NAME Michael RCIbeIt Sample
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Pltrtcll Marie V.WazeI
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
A. NAME Latis Miller Jr.
B. COUNTRY OF BIRTH UtA
17. MOTHER
A. MAIDEN NAME Helen Mary le Clelr
B. COUNTRY OF BIRTH U 6 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
000
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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(3) 0 ANNULMENT
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MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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21. SIGNATURE OF GROOM ~
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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
Relations Law ~11 to perform marriage ceremonies wit
o If checked, this license i
24. TOWN OR CITY CLERK
DATE
ate of the bride and groom named above by any person authorized by New York Domestic
New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
to be used only for the urpose of a second or subsequent ceremon .
25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
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NAME (PRINT)
TIME
MONTH
YEAR
AM
PM 07 31 08 28 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY INtc.l.css
C.
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