042
STATE OF NEW YORK I STATE FILE NUMBER "I
J (THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess DEPARTMENT OF HEALTH
CITYfTOWN Wappinger
DISTRICT 1::\68 AFFIDAVIT, LICENSE and
NUMBER
REGISTER 42 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ..J
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Andl'P.W S WilantAWir.7 11. A. FULL NAME t-Ieat~!{ A Timm~~~NAME
FIRST MIDDLE CURRENT SURNAME FIRST
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B. BIRTlI NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 1"1..4'" r.nn"
D. SOCIAL SECURITY NUMBER - ~ - -~~--~
2. RESiDENCE A. Np.w V ftrlr B. n.lI,.hARR
(Mmi ~
C. CHECK ONE 0 CITY Ooll"OWN 0 VILLAGE
AND P hk .
SPECIFY ftug eep91e
D. STREET ADDRESS .4 T~ I anA ZIP 17603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES oVlf.lo
3. A. AGE 32 3B. DATE OF BIRTH MeA' / DAS / yJj7
B. BIRTlI NAME (MAIDEN NAME), IF DIFFERENT.
C. SURNAME AFTER MARRIAGE Wilant.-..icz
(OPTIONAL - SEE REVERSE) -
D. SOCIAL SECURITY NUMBER 06a.-74- 3510
12. RESIDENCEA.~)YOrk B. W'8MFhester
c. CHECK ONE 0 CITY 0 .oWN 0 VILLAGE
AND
SPECIFY F"mr.J1lPlshtr
D. STREET ADDRESS 147 Alkamont Avenue ZIP 10583
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~O
13. A. AGE 28 13.B. DATE OF BIRTH MON~ / a~ /1;Q,l;4
14. EMPLOYMENT
A. USUAL OCCUPATION PlIysician Assistant
B. TYPE OF INDUSTRY OR BUSINESS 6r:ookIyA Hocpilal Center
15. PLACE OF BIRTH (~c't!~~ YoFk
16. FATHER
A. NAME WiUiam Alfred Timmemlans
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Rosemary Me earth)"
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE. CIVIL ANNULMENT
4. EMPLOYMENT
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A. USUAL OCCUPATION PndiRtriRt
B. TYPE OF INDUSTRY OR BUSINESS Self Employed
5. PLACE OF BIRTH (f~~oX.
6. FATHER
A. NAME Or ~lPlphlP!n J=dwRrd WiIar1ewia
B. COUNTRY OF BIRTH II 5 A
7. MOTHER
A. MAIDEN NAME E..uz~ SGReII
B. COUNTRY OF BIRTH l' S A
1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
DEATH
o 0 9
B. HOW 010 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
o
o
o
o
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATlI
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
YEAR
o
o
o
22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR C DATE
This license authorizes th arriage in New York St authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the U se of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL}
'-v-'
TIME
MONTH
YEAR
MONTH
YEAR
1 O:O$~
26. SOLEMNIZATION OCCURRED
M . A Y A
10 CIVIL
20 06 16 2003
28. PLACE WHERE MARRIAGE OCC~
A. STATE NEW YORK B. ~UNTY
04
18
R
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
27. TYPE OF CEREMONY
o ~ELlGIOUS
9D OTHER, SPECIFY
3~
5'- tJ5- 03
29. OFFICIANT /7.fi.. .'. .. fllt.- -. '. /:; f(A.)iMJ
NAME (PRINT) _ JfF.P....'" 1(}17 ~ .n--
SIGNATURE ~ .JpZ:h...., ~~.
M~~ /UFi.S~, ~/. y.
STREET 'CITYfTOWN '
30. WITNESS TO CEREMONY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF \tNILLAGE OF
SPECIFY 5c~
TITLE f~
DATE S-.15'"'-O 3
IO~.3
STATE
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE~
"