111
STATE OF NEW YORK I STATE FILE NUMBER I
] CCUNT,Qutchess (THIS SPACE FOR STATE USE ONL Y)
DEPARTMENT OF HEALTH
CITY/TOWNWappinaer 4f,itf 7 I ~(f.. /~
~~~~~CR" 368 AFFIDA VIT, LICENSE and
~~~'~J~~ 11 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
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A FULL NAME
FROM THE GROOM
Carl E. Sm ith
FIRST MIDDLE CURRENT SURNAME
FROM THE BRIDE
Judith A Fettes
FIRST MIDDLE CURRENT SURNAME
11 A. FULL NAME
B BIRTH NAME. IF DIFFERENT
B BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE Sm ith
(OPTIONAL' SEE REVERSE\t15-
o SOCIAL SECURITY NUMBER'" 13-6446
12 RESIDENCE "New York sDutchess
(STATE) (COUNTYI
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \M -
SPECIFY1'-,,-applnger
STREET ADDRES~3 Helen Drive Z1P12590
3 A. AGE38
01
MONTH
[j YES"tJ NO
~6~
YEAR
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE'
13 A AGF36 13.8. DATE OF BIRTH n7 /J~
MONTH DAY
38. DATE OF BIRTH
14. EMPLOYMENT
A USUAL OCCUPATIO~omemaker
B TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTJianover Ontario
(CITY. STATE~OUNTRY IF NOT USA)
16. FATHER
A NAMERobert Fettes
8. COUNTRY OF BIRTli:anada
17. MOTHER
A. MAIDEN NAMEMuriel Aitken
B. COUNTRY OF BIRTCl'Inl'ldl'l
18 NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
4. EMPLOYMENT
A USUAL OCCUPATIONConlraclor
B. TYPE OF INDUSTRY OR BUSINESSSelf - Employed
5 PLACE OF BIRTManhattan, New York
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A. NAME Robert Smith
B COUNTRY OF BIRTrU S A
7 MOTHER
A. MAIDEN NAME Fli7l'1hp.th 0' Kl'Iin
B COUNTRY OF BIRTHU SA
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
n
DEATH
o
o
n
(2) ::J DEATH
B HOW 010 LAST MARRIAGE END' (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B HOW 010 LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
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
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 WHO~I
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
0 0 1ST LJ [1
8i 0 0 2ND 0
on 0 0 3RD C [1
:"
:J
Z 0 0 4TH r'l [J
0
z nowledge and belief that the information I provided is true
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:r . SIGNATURE OF BRIDE ~
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23 SUBSCRIBED ANO SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
Thi5 license authorizes the marriage in New York St e of the bride and groom named above by any person authorized
Relations Law S 11 to perform marriage ceremonies within 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 CLERK 25 A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)Gloria
TIME MONTH YEAR
SEAL SIGNATURE ~ ATED1/18/2002
'--- -I ~1~iJdI~ ush Rd W lis NY 12590 ApMM 1
---v- STREET STATE ZIP 2:11
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. . ./"
SONS NAMED ABOVE ON THE RELIGIOUS 1 [jo1S,VIL
DATE AND AT THE TIME AND
PLACE INDICATED
16 2002
by New York Domestic
MONTH
YEAR
19
2002 09
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY'6tt.tTC~
OTHER, SPECIFY
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
C CITY OF 0 TOWN OF VVILLAGE OF
SPECIFY w~iitJ,,1fA ~
SIGNATURE ~ .
DOH.98 (11/98)