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COUNT,Qutchess
CITY'TOWNWappinger
~~J~k~1368
~G~'~J~F67
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Allen W. Diehl
I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE ONL Y)
,~llt 1"II'O~
L 0 SUPPLEMENTAL FILE ~
A FULL NAME
11 A FULL NAME
FROM THE BRIDE
Karen A. Tucker
MIDDLE CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
Q.
N
BIRTH NAME. IF DIFFERENT
BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Diehl
,OPTIONAL. SEE REVERSE05 3
o SOCIAL SECURITY NUMBER 3-68-7 23
12 RESIDENCE "New York B Dutchess
(ST A TEl (COUNTYI
C CHECK ONE 0 CITY 0 TOWN o(j VILLAGE
~~~ClFyWappinQers Falls
o STREET ADDRESJ~7 Old Route 9 North Apt. ZlP12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '1:J YES 0 NO
,,26 1477
DA Y YEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERS6108-72 3214
o SOCIAL SECURITY NUMBER' -
2 RESIDENCE ANew York B Dutchess
(STATEI (COUNTY)
C CHECK ONE 0 CITY 0 TOWN,.I'O VILLAGE
~~~CIFY Wappingers Falls
o STREET ADDREss7~7 Old Route 9 North Apt. ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "'0 YES 0 NO
/24 /1975
DAY YEAR
13.8. DATE OF BIRTH
03
MONTH
13 A AGF25
3 A. AG~6
11
MONTH
38. DATE OF BIRTH
4 EMPLOYMENT
A. USUAL OCCUPATION Manager
B TYPE OF INDUSTRY OR BUSINES~jzza Hut
5 PLACE OF BIRnfloUQhkeepsie. New York
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATlo~omestic Enaineer
B TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRnBronx New York
(CITY, S~ATECOUNTRY IF NOT USA)
16. FATHER
A. NAMEDaniel Tucker
8. COUNTRY OF BIRTu-eland
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6. FATHER
A. NAME Samuel Diehl
B. COUNTRY OF BIRTJJ S A
17. MOTHER
A MAIDEN NAMERridget O'brien
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
7 MOTHER
A. MAIDEN NAME Carol Dively
B. COUNTRY OF BIRTHU SA
NUMBER OF THIS MARRIAGE'l
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B HOW DID LAST MARRIAGE END? 13) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END' (3):=J DIVORCE
c. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) [J ANNULMENT
/ /
C DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? eYES 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 DAY YEAR
D ARE ANY FORMER SPOUSE IS) 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
w
en
z
w
()
:J
1 ST D 0 1 ST [J C
2ND 0 0 2ND 0 D
3RD 0 0 3RD C 0
4TH 0 0 4TH 0 0
I. bemg duly sworn, depose and say, that tD the best of my knowledge and belief that the Information I provided IS true and that I declare that no legal Impediment eXists
as to my right to enter mto the marnage state ~
21 SIGNATURE OF GROOM ~ 22 SIGNATURE OF BRIDE ~Ui( /1\ p /\# ~ I'bLJ>
'LrsE ~NT NAME
23 ~~BNSfT~~~DO~NT~0~O~RN 6~yB6E~~~~E DATE OS/22/2002
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized by New York Domestic
Relations Law S11 to perform marriage ceremonies withi 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) G_IOri _ M
p itA TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATecQ5/2212002
'-v-' '&I~t~ff1~~ush Rd in er Falls NY 12590
STREET CI Y:TOWN STATE
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 ~RELlGIOUS
DATE AND AT THE TIME AND ("
PLACE INDICATED 9 0 OTHER, SPECIFY
YEAR
ZIP
2002 07
21 2002
23
28 PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
A STATE NEW YORK B. COUNTY f)tJft!)f(;Y
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY f.8sr fiShK,'u..
'7
SIGNATURE ~
DOH-98 (11/98)
ZIP
31 WITNESS TO CEREMONY
NAME (PRINT) '5 t ~ /l ", fJl e.
SIGNATURE ~ '
fta {'II pI/'
""