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1. A. FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
nll~tin Michael Parthemore
FIRST MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
cOUNTYDutchess
CITYfTOWN Wappinger
~~J~If:1368 .
~5~:l~R37
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Michelle Kate Andresen
MIDDLE CURRENT SURNAME
~
11. A. FUll NAME
D-
I;j
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl..69 76 9500
D. SOCIAL SECURITY NUMBER !J__ - __ - ____
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUN1Y)
C. CHECK ONE 0 CITMJ TOWN 0 VILLAGE
AND W '
SPECIFY applnger
D. STREET ADDRESS 24 Four Wheel Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE~O NO
3. A. AGE21 3B. DATE OF BiRTH 04 /20 /1989
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAG~arthemore
(OPTIONAL. SEE REVERS'092_78_3159
D. SOCIAL SECURITY NUMBER
12. RESIDENCE.NY JJ.utchess
(STATE) (COUN1Y)
c. CHECK ONE 0 CIT'I"'b TOWN 0 VILLAGE
AND 'AI .
SPECIPY""'!' apPln~er
D. STREET ADDREsf4 our Wheel Drive
ZIp12590
o VEtO NO
}990
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG820 3B. DATE OF BIRTH 01 .P3
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Armnrer
B. TYPE OF INDUSTRY OR BUSINESS USMC
5. PLACE OF BIRTHCortlandt, NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME r.hri~tnrhAr .Jnhn Parthemore
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Margaret Arcara
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~R~R~~AE~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATlorWaitress
B. TYPE OF INDUSTRY OR BUSINESiood Service
15. PLACE OF BIRTJ2anbury, CT
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Thomas Brian Andresen
'B. COUNTRY OF BIRTtV S A
17. MOTHER
A. MAIDEN NAMECatherine Jean Arena
B. COUNTRY OF BIRTM S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 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 ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH OAY
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. '.- YEAR
1ST
2ND
3AD
4TH
I duly swear/affirm, aep'ose and sa~ at
as to my right to enter into the m ~l'.
21. SIGNATURE OF GROOM ~
o
o
o
o
o
o
o 0
o 0
o 0
o 0
clare that. no legal impediment exists
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 Yor State of the bride and groom named above by any person authorized
Aelations 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) n C. Mast
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
,-I'-..
{ SEAL }
'-..t-I
TIME
MONTH
YEAR
MONTH
DAY
YEAR
DATE 04/26/2010
in ers Falls NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. AY YEAR ~RELlGIOUS
3 9 0 OTHER, SPECIFY
12:23 ~~ 04
2010
10
23 2010
27
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couJv'f<'..~G-f~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
""CITY OF D TOWN OF 0 VILLAGE OF
SPECIFY 1>c.>,:!~ ~'----
TITLE~~R
..t.. z.. 0 10
60
ZIP
31. WITNESS TO CEREMONY ~
NAME(PRIND~~' ~~ '
SIGNATURE~ JV\..A....