081
COUNT~Ull.lllt;;:';:j DEPARTMENT OF HEALTH dilt/; 1-1b- t'~
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~~~~~cR'1368 AFFIDA VIT, LICENSE and
~5~'~J~FB1 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1 A FULL NAME Ryan Clary 11. A FULL NAME Lauren R. Smith
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
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best of my knowledge and belief thaI the information I provided IS true and that I declare that no legal Impediment eXists
22 SIGNATURE OF BRIDE ~ Jtllul1JV) -t:h fl ~~
USE CU~ME
23 ;~~:T~~~DO~~O~~Ot~ 6;~yBgER~~E DATE 06/17/2002
This license authorizes the marriage in New York the bride and groom named above by any person authorized by New York Domestic
Relations Law S11 to perform marriage ceremonies wi in New 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) Glori J ...
TIME YEAR MONTH
SEAL SIGNATURE ~- -' DAT~6/17/2002
'-v-I ~b'~fa~~liush Rd W;; e Falls NY 12590
STREET Y WN STATE
r CERTIFY THAT I SOLEMNIZED 27~TYPE F CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED.
Q
N
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE,f 02 64-4853
D SOCIAL SECURITY NUMBER I -
2 RESIDENCE AMassachusetts B. Franklin
(STATE) .L-. (COUNTY)
C. CHECK ONE 0 CITY-U TOWN 0 VILLAGE
~~~CIFY Greenfield
D STREETADDRES~1 Hiah Street Apt. 4 zIP01301
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEs""O NO
/10 /'1918
DAY YEAR
3. A AGF24
03
MONTH
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATIONG I S Specialist
B. TYPE OF INDUSTRY OR BuslNEsst:ranklin Regional Council
5. PLACE OF BIRT~ouahkeeDsie, New York
(CIT't"STATE/CO~NTRY IF NOT USA)
6 FATHER
A. NAME Robert Clary
B. COUNTRY OF BIRTHlJ S A
7. MOTHER
A. MAIDEN NAME Rn~p. Finrp.
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
o
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa
as to my right to enter into the m I
21 SIGNATURE OF GROOM ~
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B BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Clary
(OPTIONAL - SEE REVERSEI.o 12 60-115
D SOCIAL SECURITY NUMBER I - 9
12 RESIDENCE ANew York BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND lJll .
SPECIFy1f~8PPlnqer
D STREET ADDRES:PO H~ckensack Heights Road ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"6 NO
13 A. AGF74 13.6. DATE OF BIRTH np, 4~ ~11
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATIONTeacher
B. TYPE OF INDUSTRY OR BUSINESSWappingers Central School
15. PLACE OF BIRTf-flushinn 1. New' Yom
(CITY. STA~/C;OUNTRY IF NOT USA)
16 FATHER
A. NAMEcGeorge Smith
B. COUNTRY OF BIRTU S A
17. MOTHER
A MAIDEN NAME Joan "1r()nec
B COUNTRY OF BIRT~ J S A
lB. NUMBER OF THIS MARRIAGE 1
19. 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
MONTH DAY YEAR
o 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
ZIP
YEAR
2002 08
16 2002
9 0 OTHER, SPECIFY
2B PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~Du7Ufr?;S
TITLE
NAME (PRINT)
SIGNATURE ~
DOH-9B (11198)
((. ( /kl{:<;r
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C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY WIfP?/~6g2S fitus
31 WITNESS TO
NAME (PRINT)
SIGNATURE ~