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COUNTyDutchess
CITYITOWN WappinQer
~~~~~c;1368
~5~I~J~R1 06
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
ChristoDher D" Propfe
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
aJ1tt
~ - /~ .t/~(
L 0 SUPPI:EMENTAL FILE
FROM THE BRIDE
Jennifer L. Hail
MIDDLE CURRENT SURNAME
~
11. A. FUll NAME
FIRST
A FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Propfe
(OPTIONAL - SEE REVERSEh81 68-1343
o SOCIAL SECURITY NUMBER U -
12 RESIDENCE ANew York BDutchess
(ST A TEl (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
s~~cIFEleasant Valley
D. STREET ADDREss12 Park Drive Apt. 201
ZIP12569
o YES"!J NO
~1fi
YEAR
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL SEE REVERS&l>29 02 3080
o SOCIAL SECURITY NUMBER L - -
2 RESIDENCE ANew York B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITYvtJ TOWN 0 VILLAGE
~~~CIFY Pleasant Valley
o STREET ADDRESS 12 Park Drive Apt. 201 ZIP 12569
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE? 0 YES"b NO
An /1914
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13 A. AGF7~ 13.B. DATE OF BIRTH 17 /.in
MONTH DAY
3 A. AGF27
1n
MONTH
3B. DATE OF BIRTH
14. EMPLOYMENT
A USUAL OCCUPATlorStudent
B. TYPE OF INDUSTRY OR BUSINESsNew Paltz
15. PLACE OF BIRTJ3eaconL New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEDonald Hail
B. COUNTRY OF BIRTU 5 A
17. MOTHER
A. MAIDEN NAMEChpryt Mnr<:p
B COUNTRY OF BIRTU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESsMiIlbrook Central School
5 PLACE OF BIRT~irainia Beacn: Virainia
(C1'I'Y, STATE/COUNTRY IF NOT U~)
6. FATHER
A. NAME DouQlas Propfe
B. COUNTRY OF BIRTHU 5 A
7. MOTHER
A MAIDEN NAME SyMl't S~npini~h
B COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
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
MONTH DA Y 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
o
o
[J
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(IJ
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0:
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1 8T 0 0 18T
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is tru
as to my right to enter into the m riage. state.
21 SIGNATURE OF GROOM ~
w
en
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23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York
Relations Law S11 to perform marriage ceremonies wit n New York Slate. 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) Glori J
TIME MONTH YEAR
SEAL SIGNATURE ~
"-y-I ~~~ta~~~ush Rd 2,","0 ~~ 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
14 2002
MONTH
YEAR
17
2002 09
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY Dc~-\J~r\.>
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
10 CIVIL
OTHER, SPECIFY
29 OFFICIANT"\ '- ' (
NAME (PRINT) ~. € ,,'" I . . VY\ I \ ~ \I'
SIGNATURE ~ ~. ch. l/\f\'\oOt "- -+-
MAILING ADDRESS
i 2. $c...-\\ ('~ <<Ii' P We.
STREET CITYiTO
30. WITNESS TO CEREMONY
NAME (PRINT) 6 r i ~
SIGNATURE ~
DOH-98 (11/98)
K~c.+e\r
"6 -Ie -02-
125'0
SPECIFY W(~fe;"~Q""'<;' 'Fn/Is
TITLE
DATE