179
STATE OF NEW YORK I STATE FILE NUMBER I
:1 COUNT~utchess (THIS SPACE FOR STATE USE ONL Y)
CITYfTOWNWapPlnger DEPARTMENT OF HEALTH .$J; I~'IO'O~
DISTRIC:r1368 AFFIDAVIT, LICENSE and
NUMBER
REGISTER179 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Matthew A. Zumbrook 11. A. FULL NAME Mary E. Blackler
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME .
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belief that the information provided is true and that I declare that no legal impediment exists
22'SIGNATUREOFBRIDE~'~
U E RRENT NAME
23. DATE 11/18/2002
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New 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 CL~RK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glona J.
{ ~ ~
SEAL SIGNATURE ~.' DATE 11/18/2002
'-y-I M~Mr&m~bush Rd, Wapp' er Fils, Y 12590 10:26 AM 11
STREET CITYfTOWN S ATE ZIP PM
~~~R~~Ri~~~ IO~O~~~N~EE~ URRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE DAY YEAR ~RELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 'l.: 0 OTHER, SPECIFY
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEiI 07 64-4139
D. SOCIAL SECURITY NUMBER .. -
2. RESIDENCE ANew York B. Dutchess
(STATE) IlL (COUNTY)
C. CHECK ONE 0 CITY - U TOWN 0 VILLAGE
rr~CIFY Wappinger
D. STREET ADDRESl PIPPIn Lane
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Sales Representative
B. TYPE OF INDUSTRY OR BUSINESsLlberty Mutual Insurance
5. PLACE OF BIRT~oughkeepsie. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas Zumbrook
B. COUNTRY OF BIRTHU SA
7. MOTHER
A. MAIDEN NAME Adele Bracone
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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D1iTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
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(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D 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
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I, being duly sworn, depose and say, that tD the best of my knowled e
as to my right to enter into the marria state.
21. SIGNATURE OF GROOM ~
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Zumbrook
D. Sci~I~~I~~C~R;T~E;U:~~RSE1129-52-1492
12. RESIDENCE ANew York B. Dutchess
(STATE)"'" (COUNTY)
C. CHECK QliE. jJ CITY 0 TOWN 0 VILLAGE
~~~CIFYvvapplnger
D. STREET ADDRESs' PIPPIn lane ZIP 12590
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E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES a NO
13. A. AGE29 13.B. DATE OF BIRTH 12 )18 '}.8/2
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher -
B. TYPE OF INDIJflTRY QF\ BUSII'j.E$S Wapp,ngers Central School
15. PLACE OF BIRTHt;rOolnyn, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Stephen Stackler
B. COUNTRY OF BIRT~ ~ A
17. MOTHER
A. MAIDEN NAME Kathleen Woods
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 'I
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D'OORCE CIVIL A~ULMENT
Dl1TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) D DEATH
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
YEAR
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY O,~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF [Y~ILLAGE OF
, 7' 1"'-:' () (1-
SPECIFY ~..L., o? ;h~{ IV)