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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COUNTY Dutch~
CITYfTOWN \Alappinger
DISTRICT 1_
NUMBER
~G~~J~R 75
1 A. FULL NAME
W@yAe ~RRENT SURNAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 116 ~ ~ 9424
2. RESIDENCE A. N'tTATE) B. ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W'
SPECIFY app1nRer
D. STREET ADDRESS 2386 Route 9 D ZIP 12537
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES fI NO
MtOr1 / 10 / 1!K)6
3. A AGE 47
4. EMPLOYMENT
38. DATE OF BIRTH
A. USUAL OCCUPATION N Y S Corredion Oftioer
8. TYPE OF INDUSTRY OR BUSINESS Flshklll ~
5. PLACE OF BIRTH Ynn1ceT"~ New YnT1c
(CITY, STATElCOU RV IF NOT USA)
6. FATHER
A. NAME MaItha-: 11Ieiss
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mergeret Leu
8. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~DlVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? IVlo / "." /~
MONTH...." D*' ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.-l
11 A. FULL NAME
Lm C. BrO\oVfl;URRENT SURNAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ::nu.o..a
(OPTIONAL. SEE REVERSE' ,"""-
D. SOCIAL SECURITY NUMBER 127--68-9370
12. RESIDENCE A "IV B. n.~---
~STATE) ~'-
C. ~~6CK ONE 0 CITY ~TOWN 0 VILLAGE
SPECIFY V'-Jappinger
o STREET ADDRESS 2386 Route 9 D ZIP 12537
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ., NO
A /2'v "m
13. A. AGE 31
14. EMPLOYMENT
13.8. DATE OF BIRTH
A USUAL OCCUPATION FDDd Service
8. TYPE OF INDUSTRY OR BUSINESS DeIFY Mert
15. PLACE OF BIRTH Fit~-c--'IP''W!MlAYGFk
16. FATHER
A. NAME Rubert 8RMn
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Judy Hayden
8. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1
o
(3) ~IVORCE
o
(3) 0 ANNULMENT (2) 0 DEATH
/2Q1)2
8. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?.IVI:. / .,..
MONT~ ~.,.
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and shy, t
as to my right to enter into the m rria
~ 0 1ST 05I2112fX12. Poughkeepsie, New York
o 0 2ND
o 0 3RD
o 0 4TH
to the best of my knowledge and belief that the information I provided is true an
ate. .
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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 CLERK 25. A SOLEMNIZATION PERIOD BEGINS
09I1712fK12 Poughkeepsie, Ne\-J York
21. SIGNATURE OF GROOM ~
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en
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w
()
::i
~
{ SEAL }
'--v-'
NAME (PRINT)
o
o
o
,
DATE
by New York Domestic
TIME
YEAR
MONTH YEAR
MONTH
ZIP
11:16~~ 06
19
08 17 2003
~IL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNT~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFyd)~--ff)l' J( j"€. r
NAME (PRINT)
SIGNATURE ~
~