073
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 ~-7 4-~094
2. RESIDENCE A. NY B. n'ltr.hp~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND
SPECIFY I ~or~nop
D. STREET ADDRESS 11 Ziegler Rd ZIP 12540
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
3. A. AGE 30 3B. DATE OF BIRTH ()&:; / 1 n / 19RO
MO~'A DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION T E'cl1nir.i::m
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH Q~,r~~I/C~YrRY IF NOT USA)
6. FATHER
A. NAME lames L SpE'idell
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME K~rpn A r,ene~~e
B. COUNTRY OF BIRTH I J S A
B. NUMBER OF THIS MARRIAGE 1
9: PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
lam~~D~plli~ Srpi9MJJm'JuRNAME
COUNTY nIJtr.he~~
CITY/TOWN W::Ippinger
~~J:~c: 1 36R .
~~~~J~R 73
1, A. FULL NAME
FIRST
0.
N
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lisa Marie Re~es
MIDDLE CURRENT SURNAME
--1
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Speidell
(OPTIONAL. SEE REVERSE) 1890
D. SOCIAL SECURITY NUMBER 060-74-
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Lagrange
D. STREET ADDRESS 11 ZieQler Rd
ZIP 12540
DYES '6 NO
/1'983
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 26 3B. DATE OF BIRTH 11 ~ 1
MONTH DAY
DEATH
o
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Wappinoers Central
15. PLACE OF BIRTH Rhinebeck. Nv
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Alan Reyes
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Linda Susan Johnson
B. COUNTRY OF BIRTHU 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
(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) (CITY/COUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
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
(MON'Di, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and S I
as to my right to enter Into the a
21. SIGNATURE OF GROOM~
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.-.- YEAR
&. ;Net:>
TITLE hR.:>U(.. U~
DATE 7//z-./20/0
l/,vvn(J)c/ A/. I J,.~3
ZIP
M
~
{ SEAL}
"-.;-'
NAME (PRINT)
USE C RRE
23. SUBSCRIBED AND SWORN T fAF MED BEFO E ME
SIGNATURE OF TOWN OR CI C RK ~
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
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
o 1ST
o 2ND
o 3RD
o 4TH
and belief that the Information I provided is true and t
o 0
o 0
o 0
o 0
I declare that no legal impediment exists
..
DATE
by New York Domestic
DATE 06/29/201
ers Falls NY 12590
N STATE ~P
27. TYPE OF CEREMONY
o ~GIOUS
9 0 OTHER, SPECIFY
TIME
MONTH
YEAR
MONTH
YEAR
AM
12: 15PM
06
30
2010
08
28 2010
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY))~1z,CcS{
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY ~'I ;:;S1,1:J~L
STATE
NAME (PRINT)
SIGNATURE~