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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Peter E. Cardwell
COUN;ry
CITYITOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
vVappmger
1368
12
1. A. FUll NAME
MIDDLE
CURRENT SURNAME
FIRST
0-
N
8 BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)
o SOCIAL SECURIIY,NUMB,,^R,
2 RESIDENCE A. New york
(STATE) '" (COUNTY)
C CHECK ONE W 0 CIJY 0 TOWN 0 VILLAGE
~~~CIFY appmger
21 C Scarborougtl Lane
o STREET ADDRESS
ZIP
12~90
371-62 -37 86
Dutchess
B
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
1Ji?1I1;
J-b-I)<<
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Celine L. Vaisse
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Cardwell
(OPTIONAL, SEE REVERSE) 079 86 9809
o SOCIAL SECURITY NUMBER --
12 RESIDENCE A. New York B. Dutchess
c. CHECK ONE (STA~) CITY 0 ~WN 0 VILLAGE (COUNTY)
AND W
SPECIFY appinger
D. STREET ADDRESS 21 C Scarborough Lane ZIP
12590
DYES 0 ~O E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE'
25 / 19 ~3 A. AGE 28 13.B DATE OF BIRTH 04/
DAY YEAR MONTH
E. IS RESIDE313 WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE'
3. A. AGE 3B DATE OF BIRTH 08/
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Correction Officer
5. :LA:Y:~::I~NT:UST~P~~as~~Plds~ ~I~h~:t. at CorrectIon
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
~
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u:
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Lewis Cardwell
Ut:iA
B COUNTRY OF BIRTH
A. NAME
7. MOTHER
Barbara Nifenger
USA
1
8 NUMBER OF THIS MARRIAGE
A. MAIDEN NAME
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORa CIVIL ANNUbMENT
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
121 0 DEATH
MONTH DAY YEAR
o ARE ANY FORMER SPOUSEIS) 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
DYES 0 .,(0
03 / 1!=)73
DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Travel Consultant
B. TYPE OF INDUSTRY OR BUSINESS French Experience
15. PLACE OF BIRTH Dunkerque, Nord. France
(CITY, STATE/COUNTRY IF NOT USAI
16 FATHER
A. NAME Jacques Vaisse
B. COUNTRY OF BIRTH France
17. MOTHER
A, MAIDEN NAME Rosita Appourchaux
B. COUNTRY OF BIRTH France
1
18. NUMBER OF THIS MARRIAGE
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?
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. 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) ICITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, th
as to my right to enter into the ma
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
e and belief that the information I provided is true and that I declare that no legal impediment exists
,
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22. SIGNATURE OF BRIDE ~
DATE 02/05/2002
by New York Domestic
25 8 SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
MONTH
DAY
YEAR
204
06 2002
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
l~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY])tJ rr:ff~~ (
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
( 0 CITY OF & TOWN OF 0 VILLAGE OF
SPECIFY U)~fiPttV&t:j).....
ZIP
31. WITNESS TO CEREMONY
SxL .'
NAME (PRINT) rr.
SIGNATURE ~
c___'.
