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COUNTY Dutchess
CITY/TOWN Wappinger
~~~~~CRT 1368
~G~I~J~R 148
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.Jeremy A Ra~~
MIDDLE CURRENT SURNAME
FIRST
I"
5T A TE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
9x~t
,.. A1
( ~ Ilf ~f,'/)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Amanda A Lucas
MIDDLE CURRENT SURNAME
-.J
A FUll NAME
11 A. FUll NAME
FIRST
8 BIRTH NAME. IF DIFFERENT
8. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bass
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 055-64-7858
12 RESIDENCE A. N Y B Dutchess
(STATE~ (COUNTY)
C CHECK ONE [Y CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
o STREET ADDRESS 2 Arnold Road. Apt. 3 ZIP 12601
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? cY' YES 0 NO
13. A. AGE ?? 13.8. DATE OF BIRTH O? / O? /H~79
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Medical Office Assistant
B. TYPE OF INDUSTRY OR BUSINESS Drs. Stamm. Peters
15. PLACE OF BIRTH Pouahkeeosie, New '''ork
(CITY, S"f'ATE'COUNTRY IF NOT USA)
16. FATHER
A. NAME Clinton Lucas
8. COUNTRY OF BIRTH U_ S. A.
17. MOTHER
A. MAIDEN NAME Antnjnette I ;:) Rn~;:)
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 098-60-5216
o SOCIAL SECURITY NUMBER -- -- -- --
2 RESIDENCE A N Y Dutchess
(ST A TS) (COUNTY)
C CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 2 Arnold Road. Apt. 3
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE?
3 A AGE 24 38. DATE OF BIRTH 01 /
MONTH
ZIP 12601
D"YES 0 NO
11 / 197
DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Manufacturing
8. TYPE OF INDUSTRY OR BUSINESS IBM Corp.
5. PLACE OF BIRTH Marathon, Florida
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A. NAME Allan Bass
8. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Rit::l Tllttle
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
DEATH
o
DEATH
o
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) 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
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) (CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1 ST 0 0 1 ST 0 0
2ND 0 0 2ND C 0
3RD 0 0 3RD 0 C
4TH 0 0 4TH [J 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 declare that no legal impediment exists
as to my right to enter into the mar( ge state.
i ~~_--:/
USE CURRENT NAME
21 SIGNATURE OF GROOM ~
DATE
10/30/200 1
w
en
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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 of 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.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
by New York Domestic
TIME
MONTH
~
{ } NAME (PRINT)
SEAL SIGNATURE DATE 10/30/2001
MAlLIa ADlldalS
'-v-' STR~T MI lebus ap~~~~J Falls. ~TYrE 12590 ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO DA YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATE
AM
12:39'M
10
31
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYO..~
C. LOCATION OF CEREMONY U'
(CHECK ONE AND SPECIFY). /
o CITY OF 0 TOWN OF iYVILLAGE 0':,. lA_
SPECIFY W p,IJ~ I"~ "'" .tMa
CIVIL
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
ZIP
" ",m'''~
NAME (PRINT) ~ I flrJ
SIGNATURE ~ . -
./