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COUNTY Dutchess
CITY/TOWN Wappinger
~~~~~CRT 1 ~n8
~5~'~J~R ?4
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Fr:=lnl<ljn 1= Whitplev Ir
MIDDLE cufiMNT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
(lit!)t
" ('
5 "1' t7;1..
L D SUPPLEMENTAL FILE
FROM THE BRIDE
M~~ri A Hllsti?URRENT SURNAME
.--J
A FULL NAME
11. A. FULL NAME
FIRST
FIRST
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MAP.RIAGE
(OPTIONAL. SEE REVERSE) n7<= _ <=n-Z5QQ
D SOCIAL SECURITY NUMBER __::.1 ::.1_ ----
RESIDENCE A ~ftWE)Y nrl< B QJdtRrp~~
C CHECK ONE cY" CITY D TOWN D VILLAGE
~~~CIFY Reacon
D STREET AODRESS 37 Cross street ZIP 12508
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? [JoI\ES D NO
A. AGE 35 3B DATE OF BIRTH MONW / oQ;3 / YE1~6
4. EMPLOYMENT
A. USUAL OCCUPATION Tn Ir.k nrivpr
B TYPE OF INDUSTRY OR BUSINESS strohp.r Kino
5. PLACE OF BIRTH POI Jnhl<ppn~ip.. Npw Vorl<
(CITY. S'i"ATE.COUN'iRY IF NOT USA)
6 FATHER
A. NAME Fr:=lrklir F Whiteley. ~r
B COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME Joanne Teater
B COUNTRY OF BIRTH I J S A
B NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME (MAIDEN NAMEI. IF DIFFERENT
C S~~~~~JN~E~~t~~e~~SE)Wh jteley
D SOCIAL SECURITY NUMBER 117 -54-5033
12 RESIDENCE A. NIS'1:TE) B ~~~$.
C. CHECK ONE [JoI'CITY D TOWN D VILLAGE
~~~CIFY Rp:=lr.nn
D STREET ADDRESS ~7 Cross street
ZIP 1 ?508
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [JoI\ES D NO
MOOr~ / ~~ / ~~95
13. A AGE 36
13. B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Registered f\lIlrse - Sllpervisor
B. TYPE OF INDUSTRY OR BUSINESS Prpmipr I-Inmpr.:=Irp
15. PLACE OF BIRTH POI Inhkppn~ip_ Npw Vnrk
(CITY. ~TE:COUNfRy IF NUT USA)
16. FATHER
A. NAME Warren.\ \-11 IstiS
B. COUNTRY OF BIRTH [I S A
17 MOTHER
A. MAIDEN NAME Shirley Ann Smith
B COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
n
n
o
1 0 0
B. HOW DID LAST MARRIAGE END? (3) D~IVORCE (31 D ANNULMENT (21 C DEATH
C. DATE LAST MARRIAGE ENDED? 11/ 02 / YE1 Q88
MONTH DAY lfr"
o ARE ANY FORMER SPOUSE(S) ALIVE? D'lfES C 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
B HOW DID LAST MARRIAGE END? (31 C DIVORCE
C DATE LAST MARRIAGE ENDED?
(31 D ANNULMENT
/ /
121 D DEATH
MONTH DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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 D 0 1ST 11/02/1988 Poughkeepsie, New York C Do,;
2ND D 0 2ND D D
3RD 0 0 3RD 0 C
4TH D 0 4TH D D
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information 1 provided is true and that I declare that no legal impediment exists
as to my right to enter into the marriag~~tate. I': ., "
21 SIGNATURE OF GROOM ~ '" 22. SIGNATURE OF BRIDEd () t A CLUt ld-::;{ .( /)
USE CURRENT NAME
DATE 0~/14/?OO?
by New York Domestic
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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 State 01 the bride and groom named above by any person authorized
Relations Law &11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D II checked, this license is to be used only lor the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
"-y-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
AM
12:55'M
200
05
13 2002
15
03
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTy~nHtse
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) . /
[J CITY OF D TOWN OF r!"""VILLAGESif, JL
SPECIFY fA}4Ppr~ ~
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SIGNATURE ~
DOH,98 (11/98)