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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Steven Michael Smith
Dutchess
COUNTY 'if' .
vapplnger
CITYfTOltt'~
DISTRICtl "oe
~~~,~~~F49
NUMBER
1 . A. FUll NAME
MIDDLE
CURRENT SURNAME
a.
l'J
FIRST
B. BIRTH NAME. IF DIFFERENT
l-
S;
cc
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERS~ 11- {'--1 bbO
D SOCIAL Sf&V81lY NUMBER D t ....
NY U c..ess
2. RESIDENCE A. B.
(STATE) 01 (COUNTY)
C. CHECK O~1i. , .D 5211'( 0 TOWN 0 VILLAGE
AND vvappln~er
SPECIFY 120 New HClmuul ~ RUi::ld
D. STREET ADDRESS ZIP
E. IS R~~NCE WITHIN LIMITS OF CITY OR INCORPORATE'b~LAGE? .A"l30
3. A. AGE":: 3B. DATE OF BIRTH L..::...
MONTH DAY
4. EMPLOYMENT p' M
A. USUAL OCCUPATION Izza ~nagt er l
n.es aUf cUI
B. TYPE OF IND'e'ffi(f~~~~g;s NY
5. PLACE OF BIRTH J.1 I
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER L . R b rt S 'th
OUIS 0 e ml
A NAME USA
B. COUNTRY OF BIRTH
12G90
01
YES~rg~
/ Of
YEAR
7. MOTHER
Erin Marie DeMers
USA
B. COUNTRY OF BIRTH 1
8. NUMBER OF THIS MARRIAGE
A MAIDEN NAME
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL A~ULMENT
Dn'TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
N~g~t~~n~~I~ Kadish
.J
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAMESTflffFrENT
C. SV~~~~Nir~~~~~~As090-80-3G04
D. SOCIAL ~ITY NUMBER Dutche88
12. RESIDENCE A. (STATE) V B. (COUNTY)
c. ~~5CKWappiFj1g@fY 0 TOWN 0 VILLAGE
SPECIFY 4 Robin Lane
D. STREET ADDRESS
E. IS R~ENCE WITHIN LIMITS OF CITY OR INCORPOROO VIllAGE24
13. A. AGE 3B. DATE OF BIRTH L
MONTH DAY
14. EMPLOYMENT Teaching Assistant
A. USUAL OCCUPATION Education
B. TYPE OF IND\YatfefB ,B'GlDfSS
15. PLACE OF BIRTH
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER Phillip Albert Kadish
A. NAME U G A
B. COUNTRY OF BIRTH
125QO
ZIP
L~
.
o ~B9NO
YEAR
17. MOTHER Nancy Ruth Knanishu
A. MAIDEN NAME U G A
B. COUNlTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
~ORCE CIVIL ~ULMENT
~TH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,~.- YEAR
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) (CITYICOUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
o ledge and belief that the Information I provided Is true and that I decl re that no I~gal impediment exists
23. SUBSCRIBED AND SWORN TOIAF I BEFOIi
SIGNATURE OF TOWN OR CITY C K. 7~
This license authorizes the marriage in New York S 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.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremon .
~ 24. TOWN OR CI-::ro9W~'t, Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ~
~ r-.:,/1 J f.l...--.-- 05~;~~U1 U TIME MONTH
SEAL SIGNATURE. L, ~ ~ DATE
'-v-' ~1OIIiI31l! ush Rd, Wappingers Falls, NY 1;590 12:26 AM 05
STREET STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 27~TYP. OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 10 9 0 OTHER, SPECIFY
TITLE
~ad~
SIGNATURE.
t'v'\u_oa In'2P')I\N:.\
22. SIGNATURE OF BRIDE ~
/10/2010
York Domestic
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
DVTd{ E<3S
:;~i)O
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
IVy
,
SPECIFY
F I SI-/I<J t..L
NAME (PRINT)
SIGNATURE.