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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~kc;;r 1368 '
~5~1:~~R 25
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mark Caprara
MIDDLE CURRENT SURNAME
~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
1, A, FUll NAME
FROM THE BRIDE
Barbara Jane Meiswinkel
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENt1 am m
C. SURNAME AFTER MARRIAGE Caprara
(OPTIONAL. SEE REVERSE090_50_6857
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B.Ulster
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFYShawangunK
D. STREET ADDRESS 1-'.0 ~ox 30
FIRST
11. A. FULL NAME
..
F:l
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)090_50_6799
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkee~ie
D. STREET ADDRESS 2737 West Main St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'1J NO
11 /13 /1963
MONTH DAY YEAR
Z 1 ~ots8
IP
01.
o YES 0 NO
)959
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE50 3B. DATE OF BIRTH 07 ;re
MONTH DAY
3. A. AGE 46
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Controller
B. TYPE OF INDUSTRY OR BUSINESS Fuel Oil
5. PLACE OF BIRTH Poughkeepsie, Ny
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Clement J. Caprara, Jr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Eleanor L Tomasi
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATIONAdmistrative Assistant
B. TYPE OF INDlll1TRY Of! ~USINESS.ManUfactUrlng
15. PLACE OF BIRTHl-'ougnKeepsle, Ny
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME William F. Hamm
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Barbara M. Straley
B. COUNTRY OF BIRTJJ S A
~
18. NUMBER OF THIS MARRIAGE
9 PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
' A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANOULMENT DEaTH DrORCE CIVIL A~ULMENT D'Q'TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCg (3) CO~NULMENT ~~ DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 0 / / 20
MONTH DAY YEAR MONT~ DAY.'- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITYICOUNTv, STATE/COUNTRY, IF NOTUSA) SELF SPOUSE ~ONTH5DAY, YEAR) (CITY/COUNTY, flATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST u9/0 /2003 Kingston, NY r5
2ND 0 0 2ND 0
3RD 0 0 3RD 0
~H 0 0 4TH
I duly swear/affirm, Clep.ose and say, that to the best of my knowledge and belief that the information I provided is true and that
as to my right to enter into the marnage state.
21. SIGNATURE OF GROOM~ SIGNATURE OF BRIDE~
USE CURRE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New. York State of lhe 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
} NAME (PRINT) J. C Ma ters
{ ~ ~ ~
SEAL SIGNATURE~ TE 04/08/2010
'-.,-I MAI~~~~ sh Rd, Wapp gel's Falls, NY 12590 02:54 ~~ 04 09 2010
STREET CITYITOWN STATE ZIP
~~~R~:RT~~~ IO~O~~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE IME AY YEAR OJ8l.RELIGIOUS
DATE AND AT THE TIME AND ~ AM
PLACE INDICATED. J ~OO 0 ~I ~ Lf QtDl 9 0 OTHER, SPECIFY
by New York Domestic
MONTH
YEAR
06
07 2010
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTYU)<,;,.Je,.....
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF I)(TOWN OF 0 VILLAGE OF
SPECIFY '-0<-0->0'\ .<? t- {Y\A.r I !O, OL"'f~
~~~t~~~~ 11 ~...+
SIGNATURE~ 7~
MAILING ADDI'lE'SS
lJ.5 0-'<2. 5+
~.I~
TITLE (\ ~v e..r e", &.
DATE ,.q {)( ~ ( a, It I ;bl 0
IVy t 2.~<(b
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
SIGNATIJRF~