069
STATE OF NEW YORK I STATE FILE NUMBER I
J Dutchess (THIS SPACE FOR STATE USE ONLY)
COUNTY WI DEPARTMENT OF HEALTH
CITYfTOWN 1368 pplnger
DISTRICT AFFIDA VIT, LICENSE and
NUMBER
REGISTER 69 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Raymond Frlzsimmons 11. A. FULL NAME AndrpJiI I DeM~
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CUR E T SURNAME
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B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE F'd7JUmmons
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1llE1..R4.6677
12 RESIDENCEA. ~~)York' B. Q~ell
C. CHECK ONE 0 CITY 0 <<:lWN 0 VILLAGE
AND
SPECIFY PoughlreepRie
D. STREET ADDRESS 89 sutton PArk' RftAd ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 24 13.B. DATE OF BIRTH MOt~U / ~1
12603
YES 09NO
/1fHra
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 088-64-5228
D. SOCIAL SECURITY NUMSER
2. RESIDENCE A. New York B. Dutchess
(STATE) ~ (COUNTY)
C. ~~6CK ONE P 0 hC~?WN 0 VILLAGE
SPECIFY oug ~vv~e
D. STREET ADDRESS 89 Sutton Park Road
12603
ZIP
DYES D"" NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 25 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUST~.v OR BUSINESS I, B. E, W, Local 363
5. PLACE OF BIRTH wonx. New York
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION TP-AMp.r
B. TYPE OF INDUSTRY OR BUSINESS WAppi~ CentnlI SdlaaI
15. PLACE OF BIRTH ,g~lC!!I~Ii.~ York
16. FATHER
A. NAME Anthofl)' AlfOnKn [)p Mea
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Sallyann Mart. Riley
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
D 0
6. FATHER
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A. NAME John James Frlzsimmons
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME V1ncenza R, De Malo
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV015E CIVIL ANNo-MENT
o
DEATH
DEATH
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8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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 FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
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
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the m .
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is tr
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22. SIGNATURE OF BRIDE
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23. SUBSCRIBED AND SWORN TO EFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Sta authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within 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 CLE'::lK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glori. J. Morse
TIME MONTH YEAR MONTH DAY
SEAL SIGNATURE ~ DATE 06ID6I20D3
MA~<<d(jibush R Falls NY AM 08
'-y-I STREET CITY, OWN STATE ZIP 02:21 PM
~~~R~~~Ri~~~ 10~0~~~N~Zf~ 26 SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~L1GIOUS 10 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
07
08
05 2003
I'
03
28. PLACE WHERE MARRIAGE OCCURR~
A. STATE NEW YORK 8. COUNTY J2..dvLtt{<
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY Wuppljev'5 {;/{<"
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
31. WITNESS
SIGNATURE ~ .
DOH-98 (11/98)
NAME (P
SIGNATURE ~