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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Timothy P. Baxter
MIDDLE CURRENT SURNAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York St person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY ClER~ 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona J. Morse
e TIME MONTH
SEAL SIGNATURE ~- ATE 05/021200
'-v-I MAll~nUMIebush er Falls NY 12590 AM
STREET OWN ATE ZI 01 :25M
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY r/o
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 D RELIGIOUS 1 CIVil
DATE AND AT THE TIME AND
PLACE INDICATED. 9 D OTHER, SPECIFY
J COUNTY Dutchess
CITYITOWN Wappinger
DISTRICT 1368
NUMBER
~5~~J~R 53
1. A. FUll NAME
FIRST
Q,
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 123-62-0212
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECK ONE D CITY D,OWN D VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 16 West Booth Boulevard ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES O....NO
3. A. AGE 26 3B. DATE OF BIRTH 09 / 07 / 197
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Machinist
B. TYPE OF INDUSTRY OR BUSINESS Williams Advanced
5. PLACE OF BIRTH Beacon, New York
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
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A. NAME Alexander Miller
B. COUNTRY OF BIRTH USA
7. MOTHER
Anita Hurley
B. COUNTRY OF BIRTH Canada
B. NUMBER OF THIS MARRIAGE 1
A. MAIDEN NAME
9. 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) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
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21. SIGNATURE OF GROOM ~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica A. Schrader
11. A. FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Baxter
(OPTIONAL. SEE REVERSE) 12~66-3421
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECK ONE D CITY D TOWN D VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 18 Essex Road
12601
ZIP
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? DYES 0 ~o
08 / 17 /1979
MONTH DAY YEAR
13. A. AGE
23
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Dental Assistant
B. TYPE OF INDUSTRY OR BUSINESS Hudson River Community
15. PLACE OF BIRTH Poughkeepsie: New York
(CrrY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Raymond Schrader
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Bonnie Decker
B. COUNTRY OF BIRTH USA
1
lB. 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 (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D 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
D
o
D
1ST
2ND
3RD
D D
D D
D D
D D
at no legal impediment exists
22. SIGNATURE OF BRIDE ~
05
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~OWN OF D VilLAGE OF
SPECIFY
ZIP
"'''N~'~ ~
NAME (PRINT) ~
SIGNATURE ~ .