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COUNTY Dutchess
CITYfTOWN W~pinger
~~J:~~T 1368
~5~~J~R 41
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mark W. Vandenbrul
MIDDLE CURRENT SURNAME
-.J
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
FROM THE BRIDE
Sharon Lee Autry - Powell
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Autry
C. SURNAME AFTER MARRIAGE Vandenbrul
(OPTIONAL. SEE REVERSE) 061-44-0065
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~CIFY Fishkill
D. STREET ADDRESS 4 G Locust Court
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 112- A .19621
D. SOCIAL SECURITY NUMBER ~
2. RESIDENCE A. '1'f;1) York II. 2~~~ess
c. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY . stanfordville
D. STREET ADDRESS 6091 Route 82
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES O"'NO
13. A. AGE 50 13.B. DATE OF BIRTH 06 / 27 /1952
MONTH DAY YEAR
ZIP 12524
111
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 51 3B. DATE OF BIRTH 08 /
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Self - Employed
B. TYPE OF INDUSTRY OR BUSINESS laundromat
5. PLACE OF BIRTH POllllhkeeDsi~ New York
(CITY, imWEico"UN'ifiY IF Nu I USA)
6. FATHER
A. NAME .Ifthn VRndenbml
B. COUNTRY OF BIRTH ( I S A
7. MOTHER
ZIP 12581
DYES c::J" NO
31 / 195
DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Production Technician
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
15. PLACE OF BIRTH Newburah. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Albert Autrv
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Tinnie Rutler
B. COUNTRY OF BIRTH USA
2
A. MAIDEN NAME Jean Nol
B. COUNTRY OF BIRTH I J S A
B. NUMBER OF THIS MARRIAGE .4.
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
, 0
B. HOW DID LAST MARRIAGE END? (3) 0 'diVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? Oa/ 1.4. /
MONTH ~ DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 l'ES 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
10118/1982 Poughkeepsie, N"", Vork 0 ~ 1ST
nR/1.4.i?m, Pftl.keepQi~, New York 0 2ND
o 3RD
o 4TH
e iet that the in ormation 1 provi ed i r
18. NUMBER OF THIS MARRIAGE
DEATH
1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
.,;
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGEENDED? 07/ 06 /
MONTH J DAY
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
071011/1998 Dutchess County, NY 0 ~
o
o
o
t exists
DEATH
o
(2) 0 DEATH
1998
YEAR
(2) 0 DEATH
2002
YEAR
1ST
2ND
3RD
4TH
I, being duly sworn, depoSB and say, that to the best 0 my
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St
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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL}
'-y-I
YEAR
MONTH
YEAR
TIME
MONTH
AM
02:41tA
D4
16
2
306
14 20D3
STR
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
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY