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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c: 1368 .
~5~~~~R 66
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ar~JRPllinn ~hC~~ENT SURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FIRST Amand~I~~rie Bloo~~~~TqURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
o SOCIAL SECURITY NUMBER OR 1-78-0385
2. RESIDENCE A. NY B. nlltr.he~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOwNiIO VILLAGE
~~~CIFY Millhrnnk
D. STREET ADDRESS 18 Washington Ave ZIP 12545
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 26 3B. DATE OF BIRTH 04 / 1 ~ /19R4
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION r.nmmerr.i::ll Re::ll F5;t::lte
B. TYPE OF INDUSTRY OR BUSINESS M& T Bank
5. PLACE OF BIRTH ~~. ~~~:;~dU~,x IF NOT USA)
6. FATHER
A. NAME Thnmr~nn ~h::lW
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Fileen Hoffman
B. COUNTRY OF BIRTH LJ S A
B. NUMBER OF THIS MAR81AGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
13. A. AGI=23
3B. DATE OF BIRTH
07
MONTH
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14. EMPLOYMENT
A. USUAL OCCUPATloNPhysical Education
B. TYPE OF INDUSTRY OR BUSINESsEducation
15. PLACE OF BIRTHSharon. Conn
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEJohn Bloodgood
. B. COUNTRY OF BIRTtW S A
17. MOTHER
A. MAIDEN NAME Lisa Cahill
B. COUNTRY OF BIRTtW S A
1B. 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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swe!lr/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare tha1 no legal impediment exists
as to my nghtto enter Into the mamage state. _ /7 '/_ ~~.
21. SIGNATURE OF GROOM~'~ 2 SIGNATURE OF BRIDE~ --
USE CURR USE C NT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 06/16/2010
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
'-v-'
YEAR
MONTH
YEAR
NAME (PRINn
TIME
MONTH
11:07AM 06
PM
15 2010
17
2010
08
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRlP-\
A. STATE NEW YORK B. COUNTY'VIA .h..k.e.~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFYJ4dl b ( l) bk
10 CIVIL
29. OFFICIANT
NAME (PRINn
-
NAME (PRINn