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COUNTY Dutchess
C1TYiTOWN WappinQer
1368
11
::s I A I t: UI- Nt:W YUHI\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thorn::ls ,J Rp'::lslp.v
MIDDLE CURREi<n SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
~1;Lt
l.;r ,t~
DISTRICT
NUMBER
REGISTER
NUMBER
L C SUPPLEMENTAL FILE
FROM THE BRIDE
C::lrnll M~ C::lrthv
MIDDLE CURR~NT SURNAME
~
A F .d.. '.AJ/::
11 A. FULL NAME
FiPST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT FI::lnnp,ry
C SURNAME AFTER MARRIAGE BeCl~ley
(OPTIONAL SEE REVERSE)
D SOCIAL SECURITY NUMBER 01 R-~R-R 1 R7
12 RESIDENCE A New York B Olltches5;
(STATEI (COUNTYI
C CHECK ONE 0 CITY 0 ~OWN 0 VILLAGE
AND
SPECIFY Wappinger
D STREET ADDRESS 3 D Scarborough Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' 0 YES D~NO
13. A. AGE 33 13.B DATE OF BIRTH n7 / 03 /1968
MONIH DAY YEAR
8 = F....... \.\1.':: F DIF;:::::.E~I;
c S_';:~~;:,"'~c ~::-ER M~,::R;AGE
OP'-IC',~c . SEE RE'IERSEI
D ~=,=;._ :::_~::ITY N,-',12::~
RES :o~,C::; New York
(STA~=
C C-ECI< U.E = CITY L""'rOWN
S;EC 'Y Wappinger
D S-e:;:;T ~:C"ESS 3 D Scarborough Lane
ZIP 12590
E 's R:;S'C:;\C:; WITH~, U',I,TS OF CITY OR INCORPORATED VILLAGE' D YES ~NO
MON.Q7 / Dg6 / YEA196
3 A
,A,SE
32
3B. DATE OF BIRTH
14 EMPLOYMENT
4 EMF~OYME" T
A USUAL OCCUPATION Nllrse
B. TYPE OF INDUSTRY OR BUSINESS Westchester Medical
15. PLACE OF BIRTH Framinaham~ Massachusetts
(CITY, STATEi~UNTRY It- NOT USA)
16. FATHER
A NAME St::lnley FI::lnnpry
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Shirley Anderson
B. COUNTRY OF BIRTH I J S A
18 NUMBER OF THIS MARRIAGE 3
A ~SUAL C-:;CUPATiON NIJde8r Fnginepr
B TYPE OF INDUSTR,Y OR BUSINESS Entergy
5 PLACE OF EIRTH Roston Massachusetts
(C.T'r' STATE-COUNTRY IF NOT USA)
6 FATHER
A ~,'NE Thorn::ls Rp.::lslp.y
B COL "TRY OF BIRTH USA
7 MO~rlE"
A I,'AIDEN '.A',IE Barbara Crawford
B COL';T~Y OF BIRTH I J S A
8 NU'!EE" 0" TriS MA.RP.:AGE 1
9 PRUIC"S ',IAC'RIAGES
A "I~~'EE" C~ PREVIOUS MARRIAGES WHICH ENDED BY
C IC"CE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
?
DEATH
o
DEATH
o
o
(3) 0 ~VORCE (3) [I ANNULMENT
01/
(2) D DEATH
?OO?
YEAR
o
o
B -C.... cle _"S- MAFiFIAG:: END' (310 DIVORCE
C eA'" LJ.S'T '.IARFIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B HOW DID LAST MARRIAGE END'
MONTH
o 'PE AI;, ~CRMEP SFOUSE(S) ALIVE? DYES
DAY
[J NO
YEAR
17/
MONTH DAY
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 'l'ts C NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DA TE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
10 IF PO. ::>_S'_'. DlveRCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
:A-" C' C"CREE PLACE ISSUED AGAINST WHOM
,','CI.-- :^', YEAF CITY. STATE/COUNTRY, IF NOT USAI SELF SPOUSE
11/03/1988 Norfork, Massachllsetts
01/17/?OO? POllghkeprsie, New York
LJ [J~
[J 0....
D [J
D 0
pediment exists
1 ST D D 1 ST
2ND [] 0 2ND
3RD [j [J 3RD
4TH 0 D 4TH
I. be'n~ C'o y UiC'C,. decose and say, that to the best of my knowledge and belief that the information I provided is true an
as to rey rght ~o enter Into the marria5!f;;tate.
21 SIG',A- ~F:: c= GRCCI.I ~ -r~
23 SLES:::;:- E::::: ~'.D SVv:::R'. TO BEFORE ME
SIG'.~T ~~E:;:: (JW\:)F ':ITY CLERK....
22. SIGNATURE OF BRIDE ~
01/30/2002
UJ
CJ)
Z
UJ
U
...J
ThiS Icerse a'~lhor:zes the marriage in New York St authorized by New York Domestic
Relaticns Lao'! Si 1 to perlorm marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY
~ If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
::" TCW~, OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~"-.
{ SEAL }
'-v-'
YEAR
MONTH
YEAR
',AME pco INT)
TIME
MONTH
SIGNAT~RE ~
'.IAIL!NG ADD,RESS
AM
02:37'M
31 2002
01
31
20 2 03
ZIP
S....RE::~
I CERT,'::Y --;.- S':)LHi~IZE:J
THE "'~;':::F. .:.:2E. 2F THE PE=.
SONS '.~1-.I=::::, :"'3C. E 0\ n-:=
DATE ;",0 :... T -~E TIME A~~:)
PLACE '.D,':''=',:==
28 PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B COUNT.;J).LlTc.~
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY,
CJ CITY OF [J TOWN OF ~LAGE OF
SPECIFY t<Jt4tf:Jfl/~ ~
I~L
29 OF~ C!~',T
NAME OR ',T
ZIP
31 WITNESS T~ CE,R1MONY
NAME (PRINT) "{
SIGNATURE ~