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COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~~CRT 1368
~G~'~J~R 116
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Leonard G. Miller
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
~,tItt
tj - it, - t' ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melinda S. Moore
~
A FULL NAME
11 A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
"-
N
B BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE Miller
(OPTIONAL - SEE REVERSE) 088-68-6994
o SOCIAL SECURITY NUMBER
12. RESIDENCE A. N Y B. Dutchess
(ST A TEl J (COUNTY)
C CHECK ONE 0 CITY [J TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS2 Split Tree Drive ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rJ NO
13. A. AGE 32 138 DATE OF BIRTH 07 /25 /1'970
MONTH DAY YEAR
B BIRTH NAME IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)050_68_4487
o SOCIAL SECURITY NUMBER
2 RESIDENCE ANY B. OranQe
(STATE) (COUNTY)
C CHECK ONE 0 CITY rJ TOWN 0 VILLAGE
~~~CIFY Wallkill
o STREET ADDRESS 30 Conners Road ZIP 10941
M1ddletown ~
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES U NO
3 A. AGE 32 3B DATE OF BIRTH 04 / 25 / 1970
MONTH DAY YEAR
14 EMPLOYMENT
A. USUAL OCCUPATION Marketing
8 TYPE OF INDUSTRY OR BUSINESS Unilever
15. PLACE OF BIRTH Peekskill, New York
(CITY. STATE/COUNTRY IF NOT USA)
16 FATHER
A NAME Francis T. Moore
B. COUNTRY OF BIRTHU SA
17. MOTHER
A. MAIDEN NAME Jean Fisher
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
a 0
DEATH
o
4 EMPLOYMENT
A. USUAL OCCUPATION Banker
B TYPE OF INDUSTRY OR BUSINESS Bear Stearns
5. PLACE OF BIRTH Brooklyn, New York
(CITY. STATE/COUNTRY IF NOT USA)
6 FATHER
A. NAME Leonard G. Miller, Sr.
B COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Rose Rotondi
B. COUNTRY OF BIRTH USA
B NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
a
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
o 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
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
[(
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 D
3RD D D 3RD D D
4TH D D 4TH D D
I, being duly sworn, depose and say, th~th .e.s.t of , owledge and belief that the mformatlon I prOVided IS true and that I d~clare that no legal Impediment eXists
as to my nght to enter mto the marn ~ e. 'dI ,7 'li . If ~ A./v;;
21 SIGNATURE OF GROOM ~. "1' J vn. , . F1.LL(..Ilfi};._ ,-ro\j--( )
~. us CURRENT NAME USE CURRENT NAME
23 SUBSCRIBED AND SWORN TO EF RE ME 07/26/2002
SIGNATURE OF TOWN OR CITY ERK ~ DATE
This license authorizes the marriage in New York State f the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
[J If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24 TOWN OR CITY CLE;RK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glona J Morse
{TIME MONTH
SEAL SIGNATURE ~
'-v-' M"WCWI~8 m,ush Rd 02:59 ~~ 07
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
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:J
YEAR
STATE
27. TYPE OF CEREMONY
o ["(f;'ELlGIOUS
9 D OTHER, SPECIFY
C LOCATION OF CEREMONY
(CHECK ONE AND spECIFY)
D CITY OF ~WN OF D VILLAGE OF
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B COUNTY ptlc/,e(;,..
M
29 OFFICIANT R. 0 I - -.J- t; ~ e . '
NAME (PRINT) . tler.'f iG.' 1'. "~~""II"J:
"",,,e< ~ 1II:.,J,eJ
MAILING ADDR S
IrJ] Ja I.SM ~+. . {~l;k:1 . N1
STREET CITY TOWN .
30. WITNESS TO CEREMONY
u,z.
TITLE
G.ft.w,l'~ f'"l ~ j..
{~ Sept 2002.-
(252 '/
ZIP
31. WITNESS TO CEREMONY
SPECIFY
r:~L.k..11
DATE
STATE
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~