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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jeffrey David Mcintosh
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrro\y~wappmger
DISTRIC'iJ 68 '
NUMBER
REGISTER15
NUMBER
1 , A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSC051-58-1383
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) J. (COUNTY)
C. CHECK ONL CJ CITY" 0 TOWN 0 VILLAGE
~~~CIFY t-'ougnkeepsle
D. STREET ADDRESS 621 ::>neate KO. Lot 114
01
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 Y/-f91~
3. A. AGE38 3B. DATE OF BIRTH 03 /27
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Stay At Home Dad
5. :~::~~:,~:ue~lcf~p~l~g~ ~~ay At Home uaO
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME David Mcintosh
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jamie Hicks
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV1RCE CIVIL A~ULMENT D~TH
B. HOW DID LAST MARRIAGE END? (3)'6 DIVORCE (3) O~~ULMENT 2Bl.foDEATH
C. DATE LAST MARRIAGE ENDED? 02 / /
MONTIjO' DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITYICOUNTY, SJ:.ATElCOUNTRY .1~,N9T USA) SELF SPOUSE
1ST 02/22/2010 Columbia l,;ounty, N Y ~
2ND 0
3RD 0
4TH 0
I duly swear/affirm, depose and Y kno ledge
as to my right to enter Into th r
21. SIGNATURE OF GROOM
r
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
Lo
~
SUPPLEMENTAL FILE
FROM THE eRIDE
Samantha Lisa Delgrasso
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME~8fhT6'g1i
C. s~StlrAf'1JtAr~~rt~~~~siW6u-56-82 77
D. SOCIAL a&:ClI~1TY NUMBER 1"\ t h
NY uU cess
12. RESIDENCE A. B.
(STATE) 01 (COUNTY)
C. ~~5CK ~bugh1(e~~s~ TOWN 0 VILLAGE
SPECIFY 621 Sln::i:Ift:: Rd. Lot 17 4 12~90
D. STREET ADDRESS ZIP
E. IS R~'~ENCE WITHIN LIMITS OF CITY OR INCORPO~ VILLAGE'lj C 0
13. A. AGE 3B. DATE OF BIRTH ~
MONTH DAY
./
Yj;96gNO
YEAR
14. EMPLOYMENT
Motor Vehicle Clerk
A. USUAL OCCUPATION DM\!
B. TYPE OF INDlJlitRYRB.ilUSIt!IESSI " k
lVIan auan, l'Iew T UI
15. PLACE OF BIRTH
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
Walter Peter Delgrasso
A.NAME USA
B. COUNTRY OF BIRTH
17. MOTHER Phyllis Rae Surles
A. MAIDEN NAME U 5 A
B. COUNTRY OF BIRTH 2
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~VORCE CIVIL AtfULMENT
DEf'TH
.,
B. HOW DID LAST MARRIAGE END? (3) 0 DIVO~~ (3) CO!rNULMENT 20~@ DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONl'lll' DAY' ',- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
"
20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
cr~ms?~o't5tr)DJfffi!fgs1"'c;emy.y~NVOT USA) ~F SPOUSE
1ST 1 0 0
2ND 0 0
3RD 0 0
~ 0 0
t the information I provided is true a impediment ex' S
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
by New York Domestic
ZIP
YEAR
05
14 2010
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~~ 55
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF I!6'TOWN OF 0 VILLAGE OF
::~:1,;;
II/V
STA"PE
~:::~C6~%. ~~
MAILING A!Jj~ ~
?;:J.. 1"'4 N'~H- /I./I/JR Mc,I,~PClc
STREET CITYrrOWN
30. WITNESS TO CEREMONY
NAME (PRINT) -:S--e. '" " It) ~ i -\- e..
SIGNATURE~
SPECIFYf~.)5 ~ \L~ ~1.p -
ID~~
ZIP
31. WITNESS T~REM~NY , ~ J
"'""'"'"" ~f1 ~
SIGNATURI:~ .