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COUNTY Dutchess
CITYfTOWN Wappinger
~~J~f~ 1:'.68
~5~':l~R 24
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard W Headx,A JR
MIDDLE . RENT SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
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L 0 SUPPLEMENTAL FILE
1. A. FUll NAME
FROM THE BRIDE
Susan E Walter
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Me Cormick
C. SURNAME AFTER MARRIAGE Heady
(OPTIONAL. SEE REVERSE) 1 ~ ... 7
D. SOCIAL SECURllY NUMBER 1 J-5L-9 24
12. RESIDENCE A. NiViTlork B. ~ess
C. CHECK ONE 0 CITY [)lI'rOWN 0 VILLAGE
AND W .
SPECIFY . app10ger
D. STREET ADDRESS 3Q. Dugan Lane ZIP 12533
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 0'" NO
13. A. AGE 44 13.B. DATE OF BIRTH M~ / ~l -1 ~
14. EMPLOYMENT
A. USUAL OCCUPATION Operator
B. TYPE OF INDUSTRY OR BUSINESS Phillip~ FI@.I~tmtljc~
15. PLACE OF BIRTH ~~s~1WCo~ YoP~)
16. FATHER
A. NAME PAtrick Me r.nrmiclc
B. COUNTRY OF BIRTH Nnrlh 'M'Ann
17. MOTHER
A. MAIDEN NAME Samara Sthuder
B. COUNTRY OF BIRTH IJ 5 A
1 B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
11. A. FUll NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURllY NUMBER nRB-~4-~R30
2. RESIDENCE A. NaY nrk B. -QMf~ess
C. CHECK ONE 0 CITY r!i TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREET ADDRESS 30 Dugan' ane ZIP 12533
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES r:!f NO
3. A. AGE 43 3B. DATE OF BIRTH M~ / ~A. / ~
4. EMPLOYMENT
A. USUAL OCCUPATION t Jnp.mplnyed
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH ~~.9ao~F ~5i)
6. FATHER
A. NAME RichArd HP.A~
B. COUNTRY OF BIRTH I I ~ /1
7. MOTHER
A. MAIDEN NAME stella KRapp
B. COUNTRY OF BIRTH .... S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
001
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 'I1EATH
C. DATE LAST MARRIAGE ENDED? 05 /ct9 / 7002
MONTH D ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0
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
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DEATH
DEATH
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B. 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
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I, eing du y sworn, depose and say, thai 10 I e
as 10 my righllD enler intD the m' Ie.
21. SIGNATURE OF GROOM ~
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22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license aulhorizes Ihe marriage In New York and groom named above by any person aulhorized
Relations Law ~11 to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the U
24. TOWN OR CITY CLERK
~
{ SEAL }
'-.-I
NAME (PRINT)
MONTH YEAR
AM
PM
03
15
200
05 13 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF')l( TOWN OF 0 VilLAGE OF
SPECIFYU)O rf t ~ .f'
NAME (PRINT)
SIGNATURE ~