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COUNTY Dutchess
CITY/TOWN Wappinger
DISTRICT 1368 '
NUMBER
REGISTER 11
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jeremy Lee Speck
MIDDLE CURRENT SURNAME
I"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Leah Danielle Guerrette
~
1 , A, FULL NAME
11, A, FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
B, BIRTH NAME, IF DIFFERENT
B, BIRTH NAME (MAIDEN NAME), SDIFFERr
C, SURNAME AFTER MARRIAGE pec
(OPTIONAL. SEE REVERSEl129-7 4-8713
D, SOCIAL SEPVEUTY NUMBER
12, RESIDENCE A. NY B, uutchess
(STATE) oL (COUNTY)
C, CHECK O~ .D CITY 0 TOWN 0 VILLAGE
AND t-'ougnKeepsle
SPECIFY 59 ./ G R'"
r\.lng eorge u
D, STREET ADDRESS
12503
C, SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 364-86-9761
D, SOCIAL SECURITY NUMBER
2, RESIDENCE A, NY B, Dutchess
(STATE) (COUNlY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
~~CIFY poU~hkeepsie
D. STREET ADDRESS 9 King George Rd
1;l6Uj
ZIP
ZIP
.,
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATEf 1VILlAGE} 1 0 Y'98~O
13. A, AGE 28 3B. DATE OF BIRTH
MONTH DAY YEAR
14. EMPLOYMENT ' A 't t
A. USUAL OCCUPATION Executive SSIS an
Landscaping
B, TYPE OF INDUfjRY ~ BUSINCt
15. PLACE OF BIRTH an ury,
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME David Guerrette
, U:SA
B. COUNTRY OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1] NO
07 /29 /1979
MONTH DAY YEAR
3. A, AGE 30
3B. DATE OF BIRTH
4, EMPLOYMENT
A, USUAL OCCUPATION Restaurant Management
B. TYPE OF INDUSTRY OR BUSINESS Hospitality
5. PLACE OF BIRTH Traverse City, MI
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Unknown
B. COUNTRY OF BIRTH
7, MOTHER
A. MAIDEN NAME Mary Louise Speck
B, COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
17, MOTHER S G' bb
A MAIDEN NAME usan laco e
B, COUNTRY OF BIRTH U :s ~
lB. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
19, PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI~fRCE CIVIL ANeULMENT
D~TH
DEtJH
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEA'Jl1
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. '.- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
to
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH OAY YEAR
D, ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10, IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o 1ST
o 2ND
o 3RD
o 4TH
lief that the information I provided is true a
1ST 0
2ND 0
3RD 0
~ 0
I duly swear/affirm, depose and say, that to the best2f my kn wledge an
as to my right to enter into the ma~ .
/'"'"'"
21, SIGNATURE OF GROOM ~ ~
SE C RE E
23, SUBSCRIBED AND SWORN TO/AFFIRMEO BEFOR 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 by New York Domestic
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 urpose of a second or subsequent ceremon ,
~ 24, TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME(PRINT)~' Masterson
{SEAL SIGNATURE~I~c.~ DATE 03/04/201 YEAR MONTH
'-v-' MAI~~aafebl!fsh Rd, Wappingers Falls, NY 12590 2010 05 03 2010
STREET CITY/TOWN STATE
~~~R~~RT':J IO~O~~~N~ZEE~ 26, SOLEMNIZATION OCCURRED 27, TYPE OF CEREMON
SONS NAMED ABOVE ON THE TIME M. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. t.. ! ~fJ 9 0 OTHER, SPECIFY
YEAR
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTYD(FiCfl€$
C. LOCATION OF CEREMONY
(CHECK ONE AN;rsPECIFY)
o CITY OF ctY TOWN OF 0 VILLAGE OF
SPECIFY ~\..( :;u. Jy- 'i'~f?~lr;
~
NAME (PRINT)
SIGNATURE~
BrCv.h:,,;
SIGNATURE~
",n.u no In", /f')nn~\