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Dutchess
COUNTY Wappinger
g:~~~ig~~6a
~~~I~~~R 11
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM TJ:lEdGBOOMtt
Ro enCK 'P8 on
I
~1[[,
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
3 -1.5 -t711
L 0 SUPPLEMENTAL FILE
FRO~~ ~.~eler
~
1 A FULL NAME
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
0..
N
B BIRTH NAME (MAIDEN NAME), Pi!itfijHJT
C SURNAME AFTER MARRIAGE A50-.&.D-!1165
(OPTIONAL - SEE REVERSE~ ;:7-'1'U-'"
o SOCIAL SR~'W~rk Dull,;ht:~~
12 RESIDENCE A. (STATE). B (COUNTY)
C ~~6CK WappmQEir 0 TOWN 0 VILLAGE
SPECIFY 1 GG6 Route 9 Apt. a E
D. STREET ADDRESS
.r
BIRTH NAME, IF DIFFERENT
(STATE) (COUNTY)
C ~H6CK O'Wappm{Je'T 0 TOWN 0 VILLAGE
SPECIFY 1668 Route 9 Apt. 8 [ 12590
o STREET ADDRESS ZIP ..
E IS R~~NCE WITHiN LIMITS OF CITY OR INCORPORATEnv~LAGE' ~1 0 YES 19~~
3 A. AGE 3B DATE OF BIRTH L.. /
MONTH DAY YEAR
12590
ZIP
E. IS RE4!'1NCE WITHIN LIMITS OF CITY OR INCORPORATf()1LLAGE)l7 0 Y~~O
13. A. AGE 13.B. DATE OF BIRTH --
MONTH DAY YEAR
4. EMPLOYMENT Landscaper
A. USUAL OCCUPATION Laud~l,;aper
B TYPE OF IND~Iiis~U~atJl;Ind
5. PLACE OF BIRTH '
(CITY, STATEiCOUNTAY IF NOT USA)
6 FATHER Andrew Patton
A. NAME Irdalld
B. COUNTRY OF BIRTH
14. EMPLOYMENT
Management
A. USUAL OCCUPATION Automati~ Systenls
B TYPE OF IND~HlJg1l~~Sit:, Nt:w YOlk
15. PLACE OF BIRTH
(CITY, STATEiCOUNTRY IF NOT USA)
16 FATHER George Wheeler
A. NAME USA
B COUNTRY OF BIRTH
7. MOTHER Margaret Heaney
A. MAIDEN NAME ~cotland
B COUNTRY OF BIRTH 2
8. NUMBER OF THIS MARRIAGE
17. MOTHER
Rhoda Traver
A MAIDEN NAME USA
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AttULMENT
1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DbORCE CIVIL AroULMENT
mUTH
DtfH
v-
B. HOW DID LAST MARRIAGE END'
(3) 0 DIVORCE
(31 0 ANNULMENT
/ /
(2) 0 DEATH
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B HOW DID LAST MARRIAGE END? (3) 0 DIVO'f2 (3) C01NULMENT19~@ DEATH
C DATE LAST MARRIAGE ENDED? ,/ /
MON-m DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20.
DATE OF DECREE PLACE ISSUED AGAINST WHOM
1~~fi9!Ml.1iCfarel~Wft~~-YOotk'A) SELF SPOij,iE
1 ST ' 0 0 1 ST
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 true and that I de
as to my right to enter into the marriage
YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DA Y
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
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
21. SIGNATURE OF GROOM.
22. SIGNATURE OF BRIDE.
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Z
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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 ~11 to perform marriage ceremonies with 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 ~18Hl1KJ. Morse 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
YEAR
DATE
by New York Domestic
ZIP
2:56 AM 02
PM
,-.A-..
{ SEAL }
'-v-I
TIME
MONTH
STATE
27 TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER SPECIFY
1%.. CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED 26 SOLEMNIZATION OCCURRED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO DAY YEAR
DATE AND AT THE TIME AND ).., '36 1'2.. '"1:2. 0""
PLACE INDICATED ./ - PM J,?-:.J V-
;1~:~i~~~; 0 t/,eEY~.5: .. F ./YWCESf3. TIT~lbJtf$ O~~6- #2.f I
SIGNATURE. ~&'#~ ~ DATE !l1~ :23.}.;:k>O "2-
MAIL~Cj ADB5E~ /J -- ~ /'/./
1/ /<f3SE.e;O/,e rL . ~ (Ifff'/J/~ !7!LJ-S J /V.'7' J::2f"9o
STREET CITY TOWN STATE
30 WITNESS TO CEREMONY
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 12J1'CflES5,
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY tf)ltfJpirJ~
31.
SIGNATURE.