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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas A. Dugas, JR.
us CURRENT NAME
23 SUBSCRIBED AND SWORN TO BEFORE ME 08/12/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in y person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within York State, THIS LICENSE VALID IN N ORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR <(;loC~lr'J. 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
Dutchess
COUNTY VV
applnger
CITYiTO~~
DISTRICTJ ",,6B
NUMBER
REGISTER1;.!!:.'
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
BIRTH NAME, IF DIFFERENT
. C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERS~U f-6l-44~n
o SOCIAL SE~RITY N~BEfk out h
2. RESIDENCE A. ew 0 B. cess
(STATE) '" (COUNTY)
C CHECK O~i.. [J CITY 0 TOWN 0 VILLAGE
AND vvappllnger
SPECIFY
;3 Alpine Dnve Apt. 0
o STREET ADDRESS
125~O
ZIP
'"
Y/ffi75
YEAR
E. IS RliiffNCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGf: 38. DATE OF BIRTH 11 ~2
MONTH DAY
4. EMPLOYMENT
Maintenance
A. USUAL OCCUPATION
B TYPE OF INDt!jTRY ~R B~SI~s.Manopac parK
5. PLACE OF BIRTJ ~um or I alne
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
EThomas Dugas
A. NAM
B. COUNTRY OF BIRTH U 5 A
I errace
7. MOTHER
A MAIDEN NAME Margaret O' Connor
B: COUNTRY OF BIRTH U 51 A
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV6RCE CIVIL AlrULMENT
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
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, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
0:
W
'"
:2
:0
Z
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{ SEAL }
'-v--l
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
(l1t{
fI
q-I['7.D \~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Davis
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), D DIFFERENT
C. SURNAME AFTER MARRIAGE ugas
(OPTIONAL - SEE REVERSE062-63-3590
D. SOCIAL SNRITY NUMBER
12. RESIDENCE A ew York B Dutchess
(STATE) ~ (COUNTY)
C. CHECK'W 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY applnger
D. STREET ADDRESSJ Alpine unve Apt. u
MONTH
DAY
DffTH
14, EMPLOYMENT
A. USUAL OCCUPATIONBookkeeper
8. TYPE OF IND~i.TRY OR ~.JJSINESS~lrShon, ~hron & Chernick
15 PLACE OF BIRT..J~ount ~isco, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAM~onald Davis
B. COUNTRY OF BIRT~ ~ A
17. MOTHER
A. MAIDEN NAME Donna Matero
B. COUNTRY OF BIRT&-' 5 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DffORCE CIVIL AOULMENT
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
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
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
pediment exists
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON'
SIGNATURE ~
~01infa~
TIME
MONTH
YEAR
MONTH
DAY
YEAR
ZIP
1:07 ~~ 08
1'1 2002
13
2002 10
STATE
27. TYPE OF CEREMONY
o ~ElIGIOUS
OJ- 90 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZAT
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME
DATE AND AT THE TIME AND AM t-l
PLACE INDICATED '3 ~ CO <EJilI I
~ 29 OFFICIANT.1\ (i ~ I' ~^ ( ? I J I it " -./-~
<t NAME (PRINT) U--?4 . VV I I~
~ SIGNATURE ~ M,~fll. ~:-P::
i=~AILlN$3 ADDRESS ~
a: /,,0 b.'.1< N}~ ek"", !vvtf~
W STREET CITY/TOWN
() 30. WITNESS TO C;EREMONY
7
N-1
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY}).' h-l..d I
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF LJ
TITLE
VILLAGE OF
DATE
9/7./02-
J 2. rl r
SPECIFY
F. 'r L.. /t.-; /1
.
STATE
ZIP
31. WITNESS TO CEREMONY
\
NAME (PRINT)
SIGNATURE ~