031
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 ~H
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the Information I provided is trUj';d that I declare that no Ie al i
as to my right to enter into the mama estate.
21. SIGNATURE OF GROOM~ ~ 22. SIGNATURE OF BRIDE~
USE cu NT NAME
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 purpose of a second or subsequent ceremony.
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W } NAME (PRINT) J C. Masterson
o { TIME MONTH YEAR MONTH
::i SEAL SIGNATURE ~. DATE 04/19/2010
MAILING ADDRESS 09'53 AM 0 2010 06 18 2010
'-v-I 20 Middle ush Rd, WappinQers Falls, NY 12590 . PM 04 2
STREET CITYITOWN STATE ZIP
~~:R~~RT~~J 6~O~~~N:.z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M. DAY YEAR 0 ~RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mark James Davis
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN Wappinoer
~~J:~c~1368 .
~5~:J~R31
1. A. FUll NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSEb
D. SOCIAL SECURITY NUMBER 61-54-2209
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWI4I1J VILLAGE
~~~CIFY Wappingers Falls
D. STREETADDREss90 PaOQi Terrace ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "'6 YES 0 NO
3. A. AGE40 3B. DATE OF BiRTH 07 /21 /1969
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Purchasing Agent
B. TYPE OF INDUSTRY OR BUSINESS Insurance
5. PLACE OF BIRTHPouahkeepsie. Nv
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Gary William Davis
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Sharon Ann Cullen
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES '
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
MONTH 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) (CrrYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Suzanne Hubbard
MIDDLE CURRENT SURNAME
~
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAG~avis
(OPTIONAL. SEE REVERS'e78_58_9718
D. SOCIAL SECURITY NUMBER
12. RESIDENCE NY putchess
(STATE) (COUNTY)
C. CHECK ONE 0 CInA"'O TOWN 0 VILLAGE
~~~CIJ:agran~e
D. STREET ADDRES~ 1 Overlook Kd
ZIP' ~oU;:S
~
o YES 0 NO
ye76
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AG~4 3B. DATE OF BIRTH 02 Jj"4
MONTH
DAY
14. EMPLOYMENT
A. USUAL OCCUPATIO~lient Service Director
B. TYPE OF INDUSTRY OR BUSINES~arket Research
15. PLACE OF BIRT~oughkeepsie, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMJ;rvin Stuart Hubbard
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAMELinda Taylor
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DOATH
(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
..
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
o
o
o
DATE
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 1>v ~~
C. LOCATION OF CEREMONY
(CHECK ONE ANopECIFY)
o CITY OF ~OWN OF
TITLE If!/uisil:t"" ~ 1-"'- rU.tJt' h
DATE ...rh~1J
~fJ7/1 I
STATE
TR
30. WITNESS TO CEREMONY
NAME (PRINT) t--tA{rUC-......, "....J "D~vI5
SIGNATURE~ ~ "'\-v' ~aJJb
SPECIFY
NAME (PRINT)
SIGNATURE~