078
STATE OF NEW YORK I STATE FILE NUMBER I
J COUNTY' Dutchess (THIS SPACE FOR STA TE USE ONL Y)
CITYrrOWN ~nger DEPARTMENT OF HEALTH
DISTRICT 1 AFFIDAVIT, LICENSE and
NUMBER
REGISTER 78 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Raymond W. ZuIcDwBki, JR. 11. A. FULL NAME Laura A Warren
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 093-70.7961
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) all (COUNTY)
C. CHECK ONE D CITY D "'TOWN D VILlAGE
~~~CIFY FIShIdII
D. STREET ADDRESS 9 Charlotte Road ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES D~O
3. A. AGE 32 3B. DATE OF BIRTH 09 / 26 / 197
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Com~ Enaineer
B. TYPE OF INDUSTRY OR BUSINESS HYcerlon Solutions
5. PLACE OF BIRTH YonlaMs. New York
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME Raymond W. Zulcm:vsld Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jeanne Sh8dci'
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
2ND
3RD
4TH
I, being du y sworn, depose an sa
as to my right to enter into the ma
21. SIGNATURE OF GROOM ~
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ZUIcDwBIci
(OPTIONAL. SEE REVERSE) ftI!!ft'7'A_9918
D. SOCIAL SECURITY NUMBER UIXP" ....
12. RESIDENCE A. New York B Dutchess
(STATE) . (COUNTY)
C. CHECK ONE D CITY D ~WN D VILLAGE
~~CIFY FIShIdII
D. STREET ADDRESS 9 Charlotte ROId
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 31 13.B. DATE OF BIRTH OS /
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Manaaer
B. TYPE OF INDUSTRY OR BUSINESS 9Ftbeck'Inc.
15. PLACE OF BIRTH ~"""'.. New York
~NOTUSA)
16. FATHER
A. NAME Robert Everett Wanen
B. COUNTRY OF BIRTH USA
17. MOTHER
ZIP 12524
D YES D~O
10 /1977
DAY YEAR
A. MAIDEN NAME JMn "Arle t'~
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
-MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROlllDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
at the mformation I provid
D D
D D
D D
D D
a impediment exists
DATE CIiI23I2OO3.
any person authorized by New York Domestic
W YORK STATE ONLY.
se of a second or subse uent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
TIME
MONTH
YEAR
10:04M
PM
08
1 D CIVIL
2B. PLACE WHERE MARRIAG~
A. STATE NEW YORK It"~ ""
C. LOCATION OF CEREMONY
(CHECK ONE AN~CIFY)
D CITY OF ~TOWN OF D VILLAGE OF
SPECI~~ 7
ZIP
31. WITNESS ~REMONY ,
NAME (PRINT) I77I1Itl.Y.J 'IJ I .,. R. A.s
SIGNATURE ~ ~U. ' 'x.. <Va> "-"--