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COUNTY Dutchess
CITYrrOWN Wappinger
~~J:kc: 1368 .
~5~I:J~R 29
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Todd Martin Fowler
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Stella Berenice Varon
-1
1 . A. FULL NAME
1 1. A. FULL NAME
CURRENT SURNAME
FIRST
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTBaron
c. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE~ 11-78-5982
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE).L (COUNTY)
C. CHECK ONE lJ CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESf~ Morgan L;ourt ZIP 1 :ZO~U
"-
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES hL NO
13. A. AGE31 3B. DATE OF BIRTH 08 .-31 )978
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Stay At Home Mom
B. TYPE OF INDU~TRY Oa..BUSINEss~tay At Home Mom
15. PLACE OF BIRTHL;ali, volombla
(CITY. STATE I COUNTRY IF NOT USA)
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)"'04_11_5199
D. SOCIAL SECURITY NUMBER ....
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYotJ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 22 Morgan Court ZIP 12590
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"6 NO
06 / 17 /1964
MONTH DAY YEAR
3. A. AGE 45
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Enaineer
B. TYPE OF INDUSTRY OR BUSINESS IBM
5. PLACE OF BIRTH Louisville, Kentucky
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Donald L. Fowler
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Betty Kirtchner
B. COUNTRY OF BIRTH USA
6. NUMBER OF THIS MARRIAGE 2
16. FATHER
A. NAME Edgar Baron
'B. COUNTRY OF BIRTHColombla
17. MOTHER
A. MAIDEN NAME Stella Hernandez
B. COUNTRY OF BIRTHColombla
la. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A~ULMENT
D11TH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0 1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~ DEATH
C. DATE LAST MARRIAGE ENDED? 01 / 03 / 2008 .
MONTH JDAY 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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
DEATH
(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) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
impediment exists
1ST 0 0 1ST
2ND 0 0 2ND
3AD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, dep.ose and say, th the be?:t my knowledge and belief that the information I provided is true
as to my right to enter into the mam sta.
21. SIGNATURE OF GROOM. / . 22. SIGNATURE OF BRIDE
USE CU
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 by New York Domestic
W Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
en 0 If checked. this license is to be used only for the pu ose of a second or subsequent ceremon .
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W } NAME (PRINT) John C. Masterson
o { TIME MONTH YEAR MONTH
::J SEAL SIGNATURE ~. DATE 04/14/2010
'-v-' MAI~~G~rd'a1~ ush Rd, Wappingers Falls, NY 12590 12:49~~ 04 15 2010 06 13 2010
STREET ClTYrrOWN STATE ZIP
~~~R~~RT~~J 'o~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M Y YEAR 0 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND re" ......L-I
PLACE INDICATED. 9}! OTHER, SPECIFY > J,... J I....n l-
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY j)lJ~5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF jl(TOWN OF 0 VILLAGE OF
SPECIFY~_~~
TITLE R/6fiT RE:lJ~f)
S-<.,q,/D
J2tf.t)
NAME (PRINT)
SIGNATURE~
31. WITNESS TO CE