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COUNTyDutchess
CITY/TOWN Wappinqer
~~~~kC~1368
~G~I~J~R154
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael J. Veach
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
^
ont
j;~'IJf'~'(
L 0 SUPPLEMENTAL FILE
~
1 A FULL NAME
FROM THE BRIDE
PeQQVann W. Allen
FIRST MIDDLE CURRENT SURNAME
BIRTH NAME (MAIDEN NAME), IF DIFFERENTWalker
C SURNAME AFTER MARRIAGE Veach
(OPTIONAL. SEE REVERSEh47 69-4360
o SOCIAL SECURITY NUMBER~ -
12 RESIDENCE ANew York BDutchess
(STATE) .L (COUNTY)
C CHECK ONE D CITY D TOWN LJ VILLAGE
~~~CIFyWappinQers Falls
o STREET ADDRES~2 Clapp Avenue 1 st Floor ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "!J YES D NO
/1'4 1!176
DAY YEAR
11 A. FULL NAME
FIRST
0-
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSElo 21 60-1564
o SOCIAL SECURITY NUMBER' -
2 RESIDENCE ANew York B Dutchess
(STATE) (COUNTY)
C CHECK ONE D CITY D TOWN"f:J VILLAGE
~~~CIFY WappinQers Falls
D STREET ADDREss22 Clapp Avenue 1st Floor ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 'tJ YES 0 NO
/18 /1973
DAY YEAR
13.B. DATE OF BIRTH
11
MONTH
13. A AGF25
3 A. AGF28
01
MONTH
38. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Sales Associate
8. TYPE OF INDUSTRY OR BUSINESsLowe's Home Center
5. PLACE OF BIRTf-f:lmont. Lona Island
(CITY. STATE/COUNi"I'fY IF NOT USA)
6. FATHER
A. NAME William Veach
B COUNTRY OF BIRTHU SA
7. MOTHER
A. MAIDEN NAME Cl:Irnl Mnrin
B. COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATIONHousewife
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTJ)U Bois.. Pennsvfvania
(CITY, STATE/COUNTRY IF 1f6f"USA)
16. FATHER
A. NAMEWilliam Walker
B. COUNTRY OF BIRTt\) S A
17. MOTHER
A MAIDEN NAMEP{Jtri~i8 Silvi!':
B. COUNTRY OF BIRTt\) S A
18 NUMBER OF THIS MARRIAGE 2
B HOW 010 LAST MARRIAGE END?
(3) 0 DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW 010 LAST MARRIAGE END? (3)~ DIVORCE (3) D ANNULMENT (21 D DEATH
C. DATE LAST MARRIAGE ENDED? 10 /04 ~001
MONT.!;j, DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? '[] YES D 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
1ST 1010114200 South r.arolina D tJ
2ND D D
3RD D D
D D
al impediment exists
DEATH
o
DEATH
o
C DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
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
D
D
D
W
Cf)
Z
W
()
:J
YEAR
21 SIGNATURE OF GROOM ~
DATE 12/12/2001
of the bride and groom named above by any person authorized by New York Domestic
ew York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the purpose of a second or subsequent ceremony,
25. A. SOLEMNIZATION PERIOD BEGINS
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta
Relations Law ~11 to perform marriage ceremonies within
D If checked, this license is t
~ 24 TOWN OR CITY CLERK
} NAME (PRINT) Glo . . Morse
{SEAL SIGNATURE ~- /; I" I ~~~ATE 12/12/2001
MAI~N~aADDRESS 0:19 AM
'-v-I 2u Midd'ebush Rd i er Falls NY 12590 PM 12
STREET CI ,TOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. ~ ./
SONS NAMED ABOVE ON THE RELIGIOUS 1 VIVIL
DATE AND AT THE TIME AND
PLACE INDICATED
TIME
MONTH
YEAR
MONTH
13
2001 02
10 2002
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNT.;i)U.~
9 D OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
D CITY OF D TOWN OF ~ILLAGE OF
SPECIFY w~/J()6w ~
29. OFFICIANT
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)