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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Trevor ROQers Tait
MIDDLE CURRENT SURNAME
COUNTYDutchess
CITYrrOwNWappinger
~~~:~cR"'1368
~5~I:J~AJ4
1. A. FULL NAME
FIRST
..
1'1
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSQI.,52 66-4169
D. SOCIAL SECURITY NUMBER U -
2. RESIDENCE A NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CI'f'i'I'b TOWN D VILLAGE
~~~CIFY Union Vale
D. STREET ADDRESS38 Grangevale Rd ZIP 12540
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YEt D NO
3. A. AGE34 3B. DATE OF BiRTH 04 /22 /1976
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Student
5. PLACE OF BIRTHPOuQhkeepsie, Ny
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas John Tait Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Linda Lee Cramer
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~~RMtf~~');<tT8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
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 fSSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUNTY. STATElCOUNTRY. IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
Lo
-1
SUPPLEMENTAL FILE
FROM THE BRIDE
Vanessa Ann Gruber
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME)oi" DIFFERENT .
C. SURNAME AFTER MARRIAG~ ru ber - T alt
(OPTIONAL' SEE REVERS~67 -70-0687
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ~Y put chess
(STATE) J (COUNTY)
C. CHECK p~E . 0 prrY" D TOWN D VILLAGE
~~~CI~n10n vale
D. STREET ADDRES~ts l.:irangevale Rd
12540
ZIP
.,
D ~96NO
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPO~~ VILLAGE~
13. A. AG~3 3B. DATE OF BIRTH
MONTH DAY
14. EMPLOYMENT .
A. USUAL OCCUPATIO~urse AnestheSia
t!ealth Care
B. TYPE OF INDgSTRY 1h~USINES
15. PLACE OF BIRTA-oug eepsle, NY
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAM~tto R. Gruber
. B. COUNTRY OF BIRT~ ~ A
17. MOTHER .
A. MAIDEN NAMECarol M. Enms
B. COUNTRY OF BIRT~ ~ A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
'BVORCE CIVIL "tjNULMENT
DtJATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT (2) D DEATH
/ /
.'- YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
D
D
D
1ST
2ND
3RD
4TH
I duly swear/affirm, clep.ose and S hat to t
as to my right to enter Into the rage
21. SIGNATURE OF GROOM~
D D 1ST
D D 2ND
D D 3RD
D D 4TH
est of my knowledge and belief that the Information I provide
USE CURR
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
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked. this license is to be used onl for the urpose of a second or subsequent ceremony.
r-^-. 24. TOWN OR CII"IO ER 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) .J
YEAR
SEAL SIGNATURE
'-v-' MA~18GrOO
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
USE CURRENT NAME 04/22/2010
DATE
by New York Domestic
YEAR
06
21 2010
1~CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY nt.JTcJJ2.~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
K CITY OF D TOWN OF D VILLAGE OF
SPECIFY Pit) ~AII-e.e..p.s/-e.
ZIP
~. """,., m "'''''''''' ~
NAME (PRINT) ~
SIGNATURE~ .