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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~c~ 1368
~5~~J~R 16
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~R1rltnn 0 RP-Attv
MIDDLE CUR~ SURNAME
blAIt: riLl: NUMISI:."
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
'~WR@ E. Cr::~~NT SURNAME
.-J
1. A. FUUNAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~(M~~~~~SE) C. S~S~JN~~r:~~O~~SE)B8atty
D SOCIAL SECURITY NUMBER 7.t3-Q~L0222 D. SOCIAL SECURITY NUMBER 054 4 fi 1321
2. RESIDENCE A. N(XA . B. ~~Yort 12. RI;SIDENCEA. NlWteyork B. Q~SS
C. CHECK ONE ;.' CITY 0 TOWN 0 VILLAGE C. CHECK ONE 0 CITY [)vIrOWN 0 VILLAGE
~~CIFY Np-w Y nrfr ~~CIFY Poughkeepsie
D. STREETAODRESS ~~ Wp-m 1~1$f ~reet Apt 1& 10037 D. STREET ADDRESS 119 VaR ~gR8r Read 1110 ZIP 1260a
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? []fYES 0 NO E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Q; NO
3. A. AGE 3S 3B.DATEOFBIRTH McJi / fl? / y1B61 13.A. AGE 31 13.B. DATE OF BIRTH ~ / ii- ~i6~
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION Te1e r:nm m1lnications A. USUAL OCCUPATION Pr.ogr.am DireGter
B. TYPE OF INDUSTRY OR BUSINESS Ve~OR B. TYPE OF INDUSTRY OR BUSINESS C VI A Leeal1180
5. PLACEOFBIRTH~.qr_~~r:itroliRa 15. PLACE OF BIRTH ~i1"~JM""'VloY.
6. FATHER 16. FATHER
A. NAME nnn HnwArlf
B. COUNTRY OF BIRTH "s A
7. MOTHER
A. NAME Lloyd ~. CFeary
B. COUNTRY OF BIRTH Panama
17. MOTHER
A. MAIDEN NAME CaFeIyA 8eatty
B. COUNTRY OF BIRTH U S It
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. MAIDEN NAME Sondra Zeigler
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 0 0
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
lD, IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY,IF NOT USA) SELF SPOUSE
9 e
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
1ST
2ND
3RD
4TH
I, being duly swom, depose a say,
as to my right to enter into the m .
21. SIGNATURE OF GROOM
o
o
o
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
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23. SUBSCRIBED AND SWORN 0 EFORE ME
SIGNATURE OF TOWN OR CLERK ~ OAT
This license authorizes the marriage in New York State of the br" e and groom named above by any person authorized by New
Relations Law ~11 to perform marriage ceremonies within New York S e. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the urpose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-.-'
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
AM
PM
02 21 200 04 21 20 3
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY W~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY 'f~~~~
T
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
,.....
NAME (PRINT)
SIGNATURE ~
OOH-98 (11198)
NAME (PRINT)
SIGNATURE ~