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COUNTY
X~TYITOWN
DISTRICT
NlJIAnER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Judson
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
Dutchess
Wappinger
1368
191
~/lol~/ou
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jean Marie
Fusaro
CURRENT SURNAME
~
1. A. FULL NAME
Glover
11. A. FULL NAME
FIRST
MIDDLE
FIRST
MIDDLE
CURRENT SURNAME
l1.
N
8. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York
(STATE)
D CITY ~ TOWN :::J
Wappinger
D. STREET ADDRESS 71 Losee Road
ZIP 12590
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Du tchess
(STATE, (COUNTY)
= CITY D TOWN lX VILLAGE
Wappingers Falls
D STREETADDRESS 15 Fulton Street
Glover
116-68-4218
074-68-2018
C. CHECK ONE
AND
SPECIFY
C. CHECK ONE
AND
SPECIFY
Dutchess
t COUNTY)
VILLAGE
B.
ZIP 12590
E. IS RESIDENCE WITHiN UMITS OF CITY OR INCORPORATED VILLAGE? ~ YES [J NO
Feb. /27 / 1976
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED 'I1LLAGE? D YES x: NO
13. A. AGE 26 13.B.DATEOFBIRTH June /21 /1974
MCNTH DAY YEAR
3. A. AGE
24
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Driver
B. TYPE OF INDUSTRY OR BUSINESS Montfort Brothers
5. PLACE OF BIRTH (CITY.STAT~~O~~~~~T~~~e. New York
A. USUAL OCCUPATION Nurse
B. TYPE OF INDUSTRY OR BUSINESS Vassar Bros. Hospital
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME George Judson Glover, III
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gloria Jean Quirk
B. COUNTRY OF BiRTH USA
16. FATHER
A. NAME
John Fusaro
USA
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
Eileen Barry
USA
First
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
First
18. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(21 = DEATH
3. = ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHCM
(MONTH. DAY. YEAR) (CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ::J YES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE TriE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
W
UJ
Z
W
o
::i
1~ 0 1~ C
~ 0 ~ 0
3RD 0 3RD 0
4TH 0 4TH 0 0
I, being duly sworn, depose and say, that to the best 01 my knowledge and beliel that the informatiDn I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marri ge state. ~
21. SIGNATURE OF GROOM ~ ~ 22. SIGNATURE OF BRIDE ~ ~UlJG nl J' /WG\fl-
USE CURRENT N , J~E CURR . , 'lAME
23. SUBSCRIBED AND SWORN TO Be,.ORE ME Deputy To ClerK Sept 29 2000
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.
D II checked, this license is to be used only lor the purpose 01 a second or subsequent ceremony.
24. TOWN OR CITY CLERK Town Clerk 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) Elaine H. Snowden,
~
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL}
'-v-'
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
DATE 9/29/00
NY 12590
ZIP
10:00AM
PM
24, Wappingers Falls,
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
00
9
30
29
00
11
STATE
27. TY~ CEREMONY
o 8""RELlGIOUS 1 0 CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURR~
A. STATE NEW YORK B. COUN~t(tr:f/G:5S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF D TOWN OF ~GE OF
SPECIJV4fl-'l~ f-AU~
9 D OTHER. SPECIFY
TITLE
KC. fklEsf
CJ /30 I ,;}.~
/ ;;l5?lo
SIGNATURE ~
MAILING i(DR~ h:-n..
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) fl!![J1A....'-l C C.lc'll!..-~
SIGNATURE~ 0~~~.,..-
DOH-98 (1198)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) (J II i~ ~~ rD
SIGNATURE ~ (1{X)iDl!J1'7 ~