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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COUNTY Dlrtchess
CITYfTOWN Wappinger
~~~~~cRT 1368
~5~I~J~R 23
1. A. FULL NAME
_ J. Dress MlRENT SURNAME
FIRST
"-
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 129--5G-4098
2. RESIDENCE A. N ;irATE} 8. ~JIBS
C. CHECK ONE 0 CITY oliil TOWN 0 VILLAGE
AND n ~k:ee'
SPECIFY rOUg,.1 JBle
D STREET ADDRESS 22 Wllowbrook HeIghts ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES oil! NO
M~t / 09v / 1Z6
3. A. AGE 46
4. EMPLOYMENT
38. DATE OF BIRTH
A. USUAL OCCUPATION Park Ranger
8. TYPE OF INDUSTRY OR BUSINESS City or Peelcsklll
5. PLACE OF BIRTH ~~tl~Mf NY"
6. FATHER
A. NAME George Or...
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Margaret Rev8se
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
1D. 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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME
Chri~ 'I. Me ~T SURNAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT Downey
C. SURNAME AFTER MARRIAGE '"'I;(;SS&' r
(OPTIONAL - SEE REVERSI!;'
D. SDCIAL SECURITY NUMBER 116-46-8430
12. RESIDENCE A. N "TATE) B. p~
C. X~6CK ONE 0 CITY I;lI TOWN 0 VILLAGE
SPECIFY Putnam Valley
D. STREET ADDRESs330 DennytG\.om Road ZIP 10679
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:;j NO
~ I"
ll3:H ~Y {9~
13. A. AGE 51
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Palioe Admin. .Associate
8. TYPE OF INDUSTRY OR BUSINESS N Y C. 0 E P
15. PLACE OF BIRTH Qr~o~ x.
16. FATHER
A. NAME Jeseph DewnO)-'
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Patrlde Jones
8. COUNTRY OF BIRTHU S A
1B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 11"\0" / ~ / ~
MONT"" . 'liltIt ,,~
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~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
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1ST 0 0 1ST 01/31/2002 Carmel. NY 0 ~
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of rny knowledge and belief that the information I provided is truli~ that I declare that no legal impediment exists
as to my right to enter into the marri estate. / d~ J1, ihA _ -...
21. SIGNATURE OF GROOM ~ E CURRENT NAM 22. SIGNATURE OF BRIDE ~ -------usECiJ~R~
23. SUBSCRIBED AND SWORN T
SIGNATURE OF TOWN OR CI CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If cheeked, 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
{ } NAME (PRINT)~,Mcj~~
SEAL SIGNATU;:~> ./ ,4__ ':?7" " ~ -= DATE O'U441"VV\~a
MAILING ADDRESS " aI "1 ./',&;\AJ
'-y-I s~,Midcl.b&8h Rd, 'ftJapPiBR.,Falls. N'<TA1259O ZIP
~~~R~~~Ri:~ IO~O~~~N~ZEE.f 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND AM / " 01"2
PLACE INDICATED. :3 ~ '}(} PM . ^, / 9 0 OTHER, SPECIFY
~~~[~~~~" K;:ft~ w~. 0 LA rJ TITLE ^~t:.t(.jU./f)
SIGNATURL~ . __ DATE I, I). , b 3
MAILING ADDRESS I /
131' ~/7 d5e.-t1 ?}v,E. 'ELJc...nA-f"Iti 1'1 ( NY /0 5""/1- /~I 0
STREET -r CITYfTOWN ' STATE
3D. WITNESS TO ~EMONY \
NAME (PRINT) . 0 \I-' Cl.... J: --.,,[) I\. Q.. S IS"'Q- '--
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DATE
by New York Domestic
TIME
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
YEAR
MONTH
DAY
YEAR
AM
PM
03
15
2003 05 13 2003
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY ~-t~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY CoLd 5tr~.1
ZIP
31. WITNESS TO CEREMONY
f'(o~ e..
NAME (PRINT)
SIGNATURE ~