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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JohnG UlrlI~ JR
MIDDLE --,:IlRRENT SURNAME
23. ~~;fr~~~Do~~~~OJ'~ciO i~E. DATE 0507f.X1n.':l
This license authorizes the marriage in New York State f the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within N York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl ose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
J COUNTY Dutchess
CITYfTOWN w.pplnger
. ~~J:k~T 1"
~5~I:J~R 81
1. A. FUll NAME
FIRST
0.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) M?. -. "'U 1 D
D. SOCIAL SECURITY NUMBER _~__
2. RESlDENCEA. _VorIr B. (~
C. CHECK ONE 0 CITY OlItOWN 0 VILLAGE
AND ,......
SPECIFY v...pprp
D. STREET ADDRESS WhIt8 G8t8 R08d AP- ., EZlP 12590
E. IS RESIDENCE WITHIN UMrrs OF CITY OR INCORPORATED VILLAGE? 0 YES ~O
3. A. AGE 60 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Rhdr M.~
B. TYPE OF INDUSTRY OR BUSINESS R~III Sun AlII.NlA
5. PLACE OF BIRTH~__
6. FATHER
A. NAME .Jfthn I . rlIJf! Rr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME ~ HlmmORCl
B. COUNTRY OF BIRTH IJ S A
B. NUMBER OF THIS MARRIAGE 2
~
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 ll!IfVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? (f1/ 13 / JI82
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 'Its 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY, IF NOT USA) SelF SPOUSE
0711311982l<1~. tlllw York
DEATH
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{ SEAL }
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E
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NANED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULlNAME FIRST M~~~ice T~SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT tlden
C. SURNAME AFTER MARRIAGE UI Due
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER D49-58-7fIgR
12. RESIDENCE A. '1m)VnrIr . B.~
C. CHECK ONE 0 CITY 0 lIlbWN 0 VILLAGE
AND ,......
SPECIFY V...PP.....
D. STREET ADDRESS \MIIt8 G8ta R08d AP- ., E ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 0 ~
13. A. AGE 42 13.B. DATE OF BIRTH IT7 / 4.11: /4~
~
14. EMPLOYMENT
A. USUAL OCCUPATION ~'Y
B. TYPE OF INDUSTRY OR BUSINESS I<8Ity AatuI~
15. PLACE OF BIRTH ....1'fffvrW'I t'.IVl""'U
~~
16. FATHER
A. NAME .Jfthn Rinln1y
B. COUNTRY OF BIRTH US"
17. MOTHER
A. MAIDEN NAME Emml OdIn
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 MtoORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? Q4/ m / 1aGn
MONTH DA~ y~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 lIts 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
04102I1880 Ufdden. Co.'1MdIcut 0
o
o
DEATH
o
TIME
MONTH
YEAR
MONTH
YEAR
IP
11:~
28 2003
05
28
07
~IVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~/~ t",,;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 2'"'TOWN OF 0 VILLAGE OF
SPECIFY // )~ fll "j (0 r
NAME (PRINT)
SIGNATURE ~