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COUNTY Dutchess
CITY/TOWN Wappinger
~~~~~c: 1 368 '
~5~1:~~R69
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Inn::lt~D~L~ n::lniF!1 .16tRR~~SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Allison Elizabeth Schwartz
MIDDLE CURRENT SURNAME
.-J
1. A, FULL NAME
11, A, FULL NAME
FIRST
FIRST
B, BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb
0, SOCIAL SECURITY NUMBER 44-72-6531
2. RESIDENCE A. TN B ~hF!lhv
(STATE) (couN'fii
C. CHECK ONE ...0 CITY 0 TOWN 0 VILLAGE
AND M h'
SPECIFY emp IS
D. STREET ADDRESS 62 North Main St.: Apt 1102 ZIP 38103
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ..0 YES 0 NO
3. A. AGE30 3B. DATE OF BiRTH 01 /1? /1 ~RO
MONTH DAY YEAR
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE.Janow
o S~:'~~~~~I:VE~U~EB~~RSE130-72-2004
12. RESIDENCE ATN B$helbv
(STA,TE) (couN'fY)
C. CHECK ONE "'D CITY 0 TOWN 0 VILLAGE
~~~cIFMemohis
0, STREET ADDRES~2 North Main St.; Apt 11 02 zl~81 03
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ....0 YES 0 NO
13. A. AGF.~O 3B, DATE OF BIRTH 04 ;(9 X980
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION AttnrnF!Y
B. TYPE OF INDUSTRY OR BUSINESS Judiciary
5. PLACE OF BIRTH Hartford I Conn
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME HF!rhF!rt M::IIJrir:F! .I:::mow
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Renee May Glueck
B. COUNTRY OF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATIO~onsultant
B. TYPE OF INDUSTRY OR BUSINESSGivinQworks
15. PLACE OF BIRT~oughkeeosie, Ny
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEfV1ichael Joseph Schwartz
'B. COUNTRY OF BIRTtU S A
17. MOTHER
A. MAIDEN NAME Elizabeth Clarice Roy
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
dge and belief that the information I provided is true
o
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and
as to my right to enter into the
21. SIGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN T
SIGNATURE OF TOWN OR CI
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.
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
DATE
by New York Domestic
r-"-.
{ SEAL }
'-v-'
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
AM
02:06 PM 06
08
23 2010
25
2010
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INOICATED.
28. PLACE WHERE MARRIAGE OCCURRED .....
A. STATE NEW YORK B. COUNTY We ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ""/.TOWN OF 0 VILLAGE OF
SPECIFY~ orJ_
STREET CI N
30. WITNESS TO CEREMONY ~
NAME (PRINTl~__n_~~