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COUNTY[')lltchess
CITYrrOWNWappinger
~~~:~C:1368 '
REGISTE~4
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
lerpmM.D~~tpr HpnrlJl1~~g~uRNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Suzanne Marie Andrew
MIDDLE CURRENT SURNAME
.J
L A, FUUL NAME
1 1, A, FUUL NAME
FIRST
e, BIRTH NAME, IF DIFFERENT
e, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGJ1enderson
(OPTIONAL - SEE REVERS&l.23_72_6532
D, SOCIAL SECURITY NUMBER U
12, RESIDENCE,NY put chess
(STATE) (COUNTY)
C, CHECK ONE 0 CITV""b TOWN 0 VILLAGE
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D STREET ADDRE~ 12 Cedar Hill Road
ZIJ 2524
o YEs""'O NO
}988
YEAR
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEJ..
D, SOCIAL SECURITY NUMBER lJ51-78-2252
2, RESIDENCE ANY B. Onnnrlaga
(STATE) (COUNTY)
C, CHECK ONE 0 CITY 0 TOWNI"O VILLAGE
~~~CIFY Marr:plhlR
D, STREET ADDRESSeD East Main Street: Apt 6 ZIP 131 08
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
07 /?1 /1985
MONTH DAY YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE?
13, A, AG,22 3B, DATE OF BIRTH 01 .P2
MONTH DAY
3. A. AGF24
4, EMPLOYMENT
A. USUAL OCCUPATION C~rrpntp.r
B. TYPE OF INDUSTRY OR BUSINESS Construction
5, PLACE OF BIRTH~!?;~~~9 CO~NT~Y IF NOT USA)
6. FATHER
A. NAME Peter Allpn Hp.nrlp.r~nn
B. COUNTRY OF BIRTH LJ S A
3B, DATE OF BiRTH
14. EMPLOYMENT
A. USUAL OCCUPATIONT eacher
B. TYPE OF INDUSTRY OR BuslNEsJ;ducation
15. PLACE OF BIRT~elrose, MA
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A, NAMeP-aul Glen Andrew
. B, COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAMEDarene Janet Wilson
B. COUNTRY OF BIRT~ 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
7, MOTHER
A. MAIDEN NAME Shari I ynn Peters
B. COUNTRY OF BIRTH L J S A
8. NUMBER OF THIS MAR81AGE 1
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,".- YEAR
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
MONTH DAY
0, 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
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm. depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare th
as to my right to enter into the m ge state,
21. SIGNATURE OF GROOM~ ~ 22, SIGNATURE OF BRIDE~
o 0
o 0
o 0
o 0
o legal Impediment exists
23, SUBSCRIBED AND SWORN T FFIRMED BE OS/21/2010
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies Ithln New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
o " checked. this license is to be used onl for the purpose of a second or subsequent ceremony,
24. TOWN OR CITY CLERK 25, A. SOLEMNIZATION PERIOD BEGINS
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
MAILING ADDRESS
~ '
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
YEAR
MONTH
TIME
MONTH
YEAR
DATE OS/21/2010
ers Falls NY 12590
WN STATE ZIP
27. TYPE OF CEREMONY
o)i!l RELIGIOUS
9 0 OTHER, SPECIFY
AM
01 :56 PM 05
2010
07
20 2010
22
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTY OL,4... \.n....s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF il'VILLAGE OF
29, OFFICIANT
TITLE
DATE
SPECIFY
f,:~h kJ.l
~~A!'..f.cn>
NAME (PRINT)
SIGNATURE~