118
COUNT,Qutchess
CITYITOWNWappinQer
~~~~~CR"'1368
~5~'~J~"118
:1
"-
N
\ '-.
N
T"""
.:z
L-
~
~
(J)
Z ~
;0
en
ill
(lJ
LL
lit
L-
~
!
<K"
Z _
~
f'D
y::
~
~
~
~
~
UJ
~
a:
UJ
I
;:
rn
rn
UJ
a:
o
o
<!
1:
o
UJ
(L
rn
l-
S;
<
C
w-
"u.
:3u.
~<
z
;;
o
t:
>-
f-
o
H~w
I- 5:1- I-
~~~ ..",
f-UJZ .....
gsd~ ()
~\?8 u:
Z-
G~:S i=
:torn a:
Of->- W
w~C3 ()
t-Z",
OZ~z
-'-
A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tad Uzzle
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Paula J. Wrtson
-.J
1 L A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Van Buren
c. SURNAME AFTER MARRIAGEUzzle
(OPTIONAL - SEE REVERS""51 60-3701
D SOCIAL SECURITY NUMBER U -
12 RESIDENCE ,New York Boutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \AI .
SPECIFl"'!' apPlnger
D STREET ADDRES~ Montfort Woods Road
Zl~ 2590
o YES"O NO
uf61
YEAR
B BIRTH NAME, IF DIFFERENT
3 A. AG~3
03
MONTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13 A. AG141 13.B DATE OF BIRTH 05 ;(9
MONTH DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATloJ)ffice Manaqer
B. TYPE OF INDUSTRY OR BUSINESDamac Incorporated
15. PLACE OF BIRT5eacon. New York
(CITY, STATEICOUNTRY IF NOT USA)
4. EMPLOYMENT
A USUAL OCCUPATIONPolice Detective
B. TYPE OF INDUSTRY OR BUSINESJ,,1 T A Police Department
5 PLACE OF BIRTAtlanta. Geor~ia
(CITY, STATEICOUNTR IF NOT USA)
6. FATHER
A. NAMEBurk Uzzle
B. COUNTRY OF BIRTrU S A
16. FATHER
A. NAMPauf Van Buren
B. COUNTRY OF BIRTlJ S A
17. MOTHER
A. MAIDEN NAMEi-\gnp.!,: Pp.lir.nn
B. COUNTRY OF BIRTlJ S A
18. NUMBER OF THIS MARRIAGE 2
7. MOTHER
A. MAIDEN NAME \.srnlyn Rp.st
B COUNTRY OF BIRTHU SA
8. NUMBER OF THIS MARRIAGE2
ffi
al
:>
:l
z
o
z
'"
f-
W
W
e:
en
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
1 0 0 1 0
B. HOW DID LAST MARRIAGE END? d(o DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3)6 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATELASTMARRIAGEENDED? 09 ./21 /2000' C.DATELASTMARRIAGEENDED? 04 /17 /2002
MON,]ll DAY YEAR MONJ.jj DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? TI YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? TI 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
1sT09/21/2000 poughkeepsie, New York 0 "6 1sT04/17/2002 Poughkeepsie, New York 0 "6
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 nowledge and belief that the information I provided is tr e pediment exists
as to my right to enter into the marri
DEATH
o
21.
2, SIGNATURE OF BRIDE ~
w
(/)
Z
w
()
:J
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e of person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies withi ew 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 C~ERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)Glon J. Mo!Se
'" TIME YEAR MONTH
SEAL SIGNATURE ~- uRrJJ8/01/2002
'-.,-I ~'~t~m~liush Rd r Falls NY 12590
STREET c 'TOWN STATE
~~~R~~~Ri~~~ 'O~O~~~N~:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO DAY YEAR 0 0 RELIGIOUS 1)ZLCIVIL
DATE AND AT THE TIME AND /"itd AWrpM 0 J.1 0 ~
PLACE INDICATED .:> _ 0' I ,::...- 9 0 OTHER, SPECIFY
~~~t~~~~~\ ~~Nr ~ TITLElir ?;1f.J~Jj3'.,.q:
SIGNATURE ~ I"I 11;'Jtt.J2~a/JZ&~jJ DATEVG- 4; ;k>1)7--
MAILlNG.wDRE /J ,. J .-,. J CI
II f((;;;/;.e,eI/rJr~ rrL fV4/'rJ~ca6tfJ~i7Jug "v.!. IKCj()
STREET CITYITOWN STATE
30. WITNESS TO C
YEAR
2002 09
30 2002
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
STATE NEW YORK B. COUNTyj),)1C'Ji~~c,
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF r[;TOWN OF 0 VILLAGE OF
SPECIFY l~'fl-PPJNr>erz.,
NAME (PRINT)
SIGNATURE ~