139
]
,...
o
U)
N
,...
:z
....
~
" i'!
~ ~
Q)
Z
I'D
1ii I-
I-Q.
~(D :>
~ 4) c::c
ca::& C
~w-
5::J ~ u..
IO -' u..
~ ~ c::c
;:: - ~
--:-0 0
~I\J ~
!!!O i3
[in:
~iij
a:U1
a:",
~m
~
$i
u.
;::
a:
w
U
w
a:
w
I
;:
en
en
w
a:
o
o
'"
>-
u.
(3
W
"-
en
z z
~ 2 w
~ ~ l-
I- Z c::c
~ ~ ()
~ 8 u:
~ u- i=
~ 0 a:
b ~ w
w 0 ()
I- "'
o
z ;<;
COUNT,Qutchess
CITYrTOwNWappinger
~~~~kCR1368
~E~I~J~R139
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mark P. Manlev
MIDDLE CURRENT SURNAME
I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONL Y)
IO-~-O~
Lo SUPPLEMENTAL FILE ~
FROM THE BRIDE
Linda J. Roman
1. A. FULL NAME
11. A. FULL NAME
CURRENT SURNAME
FIRST
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Caldwell
c. SURNAME AFTER MARRIAGE Manley
(OPTIONAL. SEE REVERSE", 31 56-1611
D. SOCIAL SECURITY NUMBER '( -
12. RESIDENCE ANew York B Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
ANDp hk .
SPECIFY ou9! eepsle
D STREET ADDRES~ 1 Nassau Road
0-
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE,j, 22 50 7333
D. SOCIAL SECURITY NUMBER ( - -
2 RESIDENCE ANew York B Putnam
(STATE) (COUNTY)
C. CHECK ONE 0 CITY"tJ TOWN 0 VILLAGE
~~~CIFY Patterson
o STREET ADDRESS 702 Route 311 ZIP 12563
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES....O NO
06 /1J4 /1958
MONTH DAY YEAR
ZIP '1 ZtiUl
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
~4 ~62
DAY
04
13. A. AGrlO
3. A AGM
13.B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Construction Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Entergy N N E
5. PLACE OF BIRT"Cold Spring, New York
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Document Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Entergy N N E
15. PLACE OF BIRTJ'-IOrth Tarrytown, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Edmond Manlev
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Margaret Gabriel
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
16. FATHER
A. NAMEJames Caldwell
B. COUNTRY OF BIRTJ1 S A
17. MOTHER
A. MAIDEN NAME Marth Parker
B. COUNTRY OF BIRTM S A
18. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 1
D1JTH
a:
w
CIl
::;
:J
Z
o
Z
'"
>-
w
w
a:
>-
(f)
DEATH
1
~ ~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT ~ 0 DEATH
C. DATE LAST MARRIAGE ENDED? 07 /06 /1997 c. DATE LAST MARRIAGE ENDED? 04 /15 /19 9
MONT,tjr DAY YEAR MONTl;lf DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 08/31/1981 San DieQo, California r'i . 0 1ST 01/21/1993 Westchester County, New [j'" 0
2ND 0 0 2ND 04/15/1999 Poughkeepsie, New York r5 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 my knDwledge and belief that the information I provided is true and no Ie al impediment exists
as to my right to enter into the marr' ge state.
J
22. SIGNATURE OF BRIDE
21. SIGNATURE OF GROOM ~
w
en
z
w
()
:J
23. SUBSCRIBED AND SWORN TO BEF E ME
SIGNATURE OF TOWN OR CITY CL K ~ D
This license authorizes the marriage in New York and grDDm named above by any person authorized by New York Domestic
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 purpose of a second or subsequent ceremony.
~ 24 TOWN OR CITY CLERK 25 A SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Gloria J: Morse . .
(J 09/03/2002 TIME MONTH
SEAL SIGNATURE ~--- TE
'-,,-I M~'Mf~M~bush Rd er Falls, NY 12590 09:59 ~~ 09
STREET ITY/TOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. - /
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 IVRELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
10 CIVIL
28 PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B COUNTY p"l'kk l Sr
4; aJA 10 or '200
" 0"''''''' =1: ~ \ ~ t;t\./
:::::::T~ .~~ ~ "' l
MAILING ADDRESS ,..., s J 11
'? l :J (, tf) '1 lTv'.(
STREET CITY/TOWN
30. WITNESS TO CE~ONY
NAME iP,RINTI t::. cA. rvt
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF c;(ILLAGE OF
SPECIFY ~r ~ '" ~ e...~ 1=" 1/.t }J r
TITLE
R ~ ve V'~ '^ J
JD/ r; 11)(
AJY (2'2 O~
DATE
Allot{ '" y
STATE
SIGNATURE ~
DOH.98 (11/98)
31.
NAME (PRINT)
SIGNATURE ~