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COUNTY Dutchess
CITYITOWN Wappinger
~~J~kc; 1368
REGISTER 94
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
EdlNard J. Becker
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mi~e M. ~TSURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) nan '~8269
D. SOCIAL SECURITY NUMBER UU\r"o;xr _
2. RESIDENCE A. N Y 8. nlJt~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 120 Channlngvllle Road. 1 Cp
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~
(OPTIONAL - SEE REVERSEr -.--
D. SOCIAL SECURITY NUMBER 062--68 8219
12. RESIDENCE A N ('!rATE) 8. ~
C. CHECK ONE 0 CITY Qjl'TOWN 0 VILLAGE
AND ~ Y'lha.-...-i
SPECIFY rOl""-I~e
D. STREET ADDRESS 120 Channl~ll. Road, 1 OIP 12690
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [1jI' NO
MUt / Zly ~'9Zil
12590
YES ~ NO
/tp
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MO~ /~
3_ A. AGE 36
13. A. AGE ]Q
14. EMPLOYMENT
A. USUAL OCCUPATION Mecical .....istant
8 TYPE OF INDUSTRY OR BUSINESS Rhinebedc Wom...'s
15. PLACE OF BIRTH ~~'rE7~),'AEAc~::)
16. FATHER
13_8 DATE OF BIRTH
38 DATE OF BIRTH
4_ EMPLOYMENT
A. USUAL OCCUPATION Paramecic
8 TYPE OF INDUSTRY OR BUSINESS Alamo Ambulance
5_ PLACE OF BIRTH Poughkeegsle, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A NAME Edward Hasbrook Becker. II
8 COUNTRY OF BIRTH USA
A. NAME .Joseph Percopo
8 COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Madeline De CepFIe
8 COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
7. MOTHER
A. MAIDEN NAME Ann Marie De Merco
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
o
(2) 0 DEATH
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9. PREVIOUS MARRIAGES
A_ NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
8 HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 09 / 2001
MONT~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? LI YES 0 NO
10_ IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
~~NJ;ti....o~..ylAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1 ST wnMl.4JU1 PouahkeeDsle. N Y ~ 0 1 ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and beltef that the information I prOVided is tru4e a d that I declare that no legal Impediment eXists
as to my nght to enter Into the marn sat /J _ J. ~
21_ SIGNATURE OF GROOM ~ 22 SIGNATURE OF BRIDE ~ ' · flj.ffi- jp ,
USE CURR T NAME
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of t e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony_
~ 24. TOWN OR CITY CL~RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona J. Morse
TIME MONTH YEAR MONTH DAY
SEAL SIGNATU I)
'-v-I ~
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON'
YEAR
0:23 AM
PM
iT
24
2003 09
21 2003
1 r/cIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY ~tno.h\
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF rJf VILLAGE OF
29. OFFICIANT
NAME (PRINT)
SPECIFY
NAME (PRINT)
SIGNATURE ~