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COUNTY Dutch~
CITYiTOWN Wappinger
~~~~kc~ 1368
~5~~J~R 48
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COlan I1Auid AnrfP-nmn
......, MIDDLE CURRENT SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
U'Da Bern Koki..m~
. MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
a.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE K()lriasmencw.
(OPTIONAL - SEE REVERSE,'
D. SOCIAL SECURITY NUMBER OR?-6;2-0730
12. RESIDENCE A. Vi"'gAq~ B. (COUNTY)
C. CHECK ONE Pi! CITY 0 TOWN 0 VillAGE
~~~CIFY AlevandriA
D. STREET ADDRESS 24~ MenoIdn Drive tI:202 ZIP 22302
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 25 13.B. DATE OF BIRTH ~ /?11 ..(.9177
MOr<TH "-ClJ\Y /)~ \>EAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) "'...,. '7~ ~1~
D. SOCIAL SECURITY NUMBER ~_~;}L_~
2. RESIDENCE A.Virainia B.
(!!'i'JiTE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VilLAGE
~~~CIFY Alexandria
D STREET ADDRESS 2423 MenoIcIn DrIve tI202 ZIP 22302
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? f!! YES 0 NO
3. A. AGE 26 3B. DATE OF BIRTH Mm / ~ / 1~
4. EMPLOYMENT
A. USUAL OCCUPATION ReRe8rcher
B. TYPE OF INDUSTRY OR BUSINESS HQgIn & Hartson
5. PLACE OF BIRTH ~~ s~l!u~"'~~
6. FATHER
A. NAME Howard Anderson
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Cla'lda Selmon
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
o
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS G~ Unlv IIlIW ct
15. PLACE OF BIRTH ~~T~''N~ Vm'k
16. FATHER
A. NAME ~ KnkillKmervm
B. COUNTRY OF BIRTHGr~
17. MOTHER
A. MAIDEN NAME Christina Cost8s
B. COUNTRY OF BIRTH I J S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT DEATH
000
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
R 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
2D. 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
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
o 0
o 0
o 0
o 0
t at no legal impediment exists
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~H 0 0 ~H
I, being duly sworn, depose and say, 1hat to the best of my knowledge and belief that the information I provided is tru
as to my right to enter into the mar' ge state.
21. SIGNATURE OF GROOM ~
W
en
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o
:::::i
23. SUBSCRIBED AND SWORN TO BEF E 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 911 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
DATE n41?812OO3
by New York Domestic
,-"-..
{ SEAL }
'-.,,-I
TIME
MONTH
DAY
YEAR
MONTH
YEAR
DATE n4nRf.XlO3
09:10 AM 04
PM
29
06
27 2003
ZIP
STATE
27. TYPE OF CEREMONY
D)( RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY !N'"'{t:ftESS
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )Q TOWN OF 0
~ PM 05. 12. o"!
~~~tr~~~(RE'l)~~I~ vnJ(=~ 'rJ TITLE
SIGNATURE ~ ~ ~. ~ DATE
MAILING ADDRtSS
I SOo 1""""'" 7.7 : WAl'!'fNG ~ S _ FALL S
STREET CITYiTOWN
30. WllNESS TO CEREMONY \ _
NAME (PRINT) .1{ 1 cc l f_ K 0 "\ I Q 6 V\\ -en 0 .s
SIGNATURE~ Lt/Lr .I',.f~~
~1e:1
MA.'l. 12. '2..COS'
~ \.(. (~5qO
STATE
VillAGE OF
SPECIFY WAPrIt-J bEt<.
31.
NAME (PRINT)
SIGNATURE ~