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COUNTY Dutchess
CITYiTOWN Wappinger
1368
49
I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE ONL Y)
1J1lt S/ll//:{
Lo SUPPLEMENTAL FILE ~
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Sh;::)wn T Finn 11 A. FUll NAME
MIDDLE CURRENT SURNAME
FIRST
FROM THE BRIDE
.Jennifer I Fazer
MIDDLE CURRENT SURNAME
1 A FUll NAME
FIRST
0-
N
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 11 ?_~~_ '"'10("\
o SOCIAL SECURITY NUMBER _ _ _ DD J _ Q;:!
2 RESIOENCE A N Y B. rJutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY [JoI'rOWN 0 VILLAGE
ANO
SPECIFY Wappinger
o STREET AOORESS 19 D Whitegate Drive ZIP 12590
E IS RESIOENCE WITHiN LIMITS OF CITY OR INCORPORATEO VillAGE? 0 YES 01 NO
3 A. AGE 28 36 DATE OF BIRTH MONQ1 / oJ 4 / YEA191
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Finn
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 051-nO-15?5
12 RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C CHECK ONE oo'CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
o STREET ADDRESS 17 Oakwood Blvd. ZIP 12603
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE? oIYES 0 NO
13 A. AGE 29 13B. DATE OF BIRTH 02 / 11 /1973
MONTH DAY YEAR
4 EMPLOYMENT
14. EMPLOYMENT
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Su.
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A. USUAL OCCUPATION Trnnper
6 TYPE OF INDUSTRY OR BUSINESS N Y S Pnlice
5 PLACE OF BIRTH Brook1vnu New Yark
(CITY, STATrn;o NTRY IF NOT USA)
6 FATHER
A NAME Thnm;::)!=; H Finn
B COUNTRY OF BIRTH I J S A
A. USUAL OCCUPATION Merchandize Coordinator
B. TYPE OF INDUSTRY OR BUSINESS I iz Claiborne
15. PLACE OF BIRTH Los Anaeles~ California
(CITY, STATE,~UNTRY Ie NOT USA)
16. FATHER
A, NAME A/;::)n Fa7er
6 COUNTRY OF BIRTH I J S A
17. MOTHER
A, MAIDEN NAME Linda Delise
6 COUNTRY OF BIRTH II S A
18, NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
(1 (1
DEATH
o
7. MOTHER
A. MAIDEN NAME Susan Benney
B. COUNTRY OF BIRTH I J S A
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
(1
o
o
B. HOW DID lAST MARRIAGE END? (3) = DIVORCE
C DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
121 0 DEATH
(3) 0 ANNULMENT
/ /
(3) 0 ANNULMENT
/ /
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, STATEiCOUNTRY, IF NOT USA) SELF SPOUSE
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, STATEiCOUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the marri ~'
",7, 'f
21 SIGNATURE OF GROOM ~ . //
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ediment exists
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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 Sta e of the bride and groom named above by any person authorized
Relations Law S11 to perform marriage ceremonies within 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
DATE
by New York Domestic
TIME
MONTH
~
{ SEAL }
"-y-I
AM
02: 4CfM
05
02
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
1 C CIVIL
2B PLACE WHERE MARRIAGE, OCCUR~ _.
A. STATE NEW YORK B COUNT'IJ.U lC1(;E;.'
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
X CITY OF 0 TOWN OF 0 VILLAGE OF '
. SPECIFY ~ u CH k t:;: f],....5/ E.
/VI, itA. Y 5.s C u J4.etl
~