092
STATE OF NEW YORK I STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
] COUNTY DI~$ DEPARTMENT OF HEALTH
CHYfTOWN Wapplnger
~ DISTRICT AFFIDAVIT, LICENSE and
NUMBER 1368
REGISTER 92 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE
FROM THE GROOM FROM THE BRIDE
1. A. FU LL NAME J&FY L YaRM*sURNAME 11. A. FULL NAME ~1!M1lB8 L S~T SURNAME
FIRST FIRST
f--
Z
W
en
W
III
g
OJ
o
I
en
z
o
;::
<(
a:
f--
UJ
(3
W
a:
W
Cl
<(
a:
a:
<(
::<
u.
o
W
f--
<(
II
u:
;::
a:
W
II
W
a:
W
I
~
UJ
UJ
W
a:
o
o
<(
>-
u.
t3
W
0-
UJ
~~~ w
t;j~~ ....
a::X: N c:(
t;~~
OjllW ()
::<ClcS u::
~~U) _
G~~ t-
ffoUJ a:
Of-->- W
w~<5 ()
b~U}
Z::J~
0-
N
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~~~~~JNW~~~t~~e~~SE) Y 8RaF81la
o SOCIAL SECURITY NUMBER 108 66 9751
12. RESIDENCE A ~!."8chll8etIB B W~er
c. ~6CK ONE 0 CITY 0 oijiOWN 0 VILLAGE
SPECIFY Westbarough
o STREET ADDRESS """1 Homestead Boulevard'P
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 23 13.8. DATE OF BIRTH MOW / ;18
14. EMPLOYMENT
A. USUAL OCCUPATION student
B. TYPE OF INDUSTRY OR BUSINESS Mass, College of Pharm.
15. PLACE OF BIRTH (~ ~s'tork -
16. FATHER
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 09)..64-5796
2. RESIDENCE A. ~Slchusetls B (W~er
C. CHECK ONE 0 CITY D.,OWN 0 VILLAGE
AND
SPECIFY Westborougb
D. STREET ADDRESS ???1 Homestead Boldevarct 01581
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D~O
3. A. AGE 23 3B. DATE OF BIRTH MONT11 / DQa / YE1~7
4. EMPLOYMENT
A. USUAL OCCUPATION Electl:idan
8. TYPE OF INDUSTRY OR BUSINESS Loeal 96
5. PLACE OF BIRTH (~~9N~~9f!c
6. FATHER
01581
YES D,.iJO
/1$8)
A. NAME James RiGham Schaffer
B. COUNTRY OF BIRTH U S ^
17. MOTHER
A. MAIDEN NAME Unds reR)'
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
....
:>
<(
c
u::
u.
;:;<(
A. NAME John C. Ysnsrella
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Margaret RlklAS
B. COUNTRY OF BIRTH U S ~,
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
o
(2) 0 DEATH
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and s ,that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the m ri estate.
21. SIGNATURE OF GROOM ~
qfp 01 ~'if' it.~;
U CDRR~:A~E 1200
22. SIGNATURE OF BRIDE ~
w
(/)
Z
W
()
:::i
23. SUBSCRIBED AND SWORN TO B FORE ME
SIGNATURE OF TOWN OR CITY CLERK~
This license authorizes the marriage in New York St bride and groom named above by any person authorized by New York Dornestil
Relations Law 911 to perform marriage ceremonies withi ew 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
YEAR
MONTH
YEAF
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
TIME
MONTH
07
19
09
16 2003
TE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATI OCCURRED
TIME MO. DAY
AM
3:00 PM
10 CIVIL
A. STATE NEW YORK B. COUNTY Dutchel
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0
YEAR
'03
13
29. OFFICIANT
NAME (PRINT)
TITLE Reverend
VILLAGE OF
DATE
9/13/2003
SPECIFY Poughkeepsie
NY
STATE
31.
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
SIGNATURE