189
COUNTY
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REGISTER
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael E.
FIRST MIDDLE
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
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
Elaine Town
Dutchess
Wappinger
1368
189
,. A. FULL NAME
Bri~gs
CURRE T SURNAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
Q CITY GC TOWN Q VILLAGE
Poughquag
19 Bush Creek Ln.
151-54-4467
C. CHECK ONE
AND
SPECIFY
12570
D STREET ADDRESS
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
3 A. AGE 41 3B.DATEOFBIRTH Jan. / 06 /1959
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Driver
B. TYPE OF INDUSTRY OR BUSINESS PouczhkeelJs ie Ford
5. PLACEOFBIRTH Paterson. New Jersey
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME John E. Briggs
B. COUNTRY OF BIRTH USA
MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Mary E. McCrae
USA
First
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (31 LJ DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ::: YES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
D
D
21. SIGNATURE OF GROOM ~
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{ SEAL}
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I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONLY)
/,cl~/cO
Lo SUPPLEMENTAL FILE ~
11. A. FULL NAME
FROM THE BRIDE
Monica M.
FIRST MIDDLE
Mack
CURRENT SURNAME
B. BIRTH NAME IMAIDEN NAME), IF DIFFERENT
C. SURNAMEAFTERMARRIAGE Mack-Briggs
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 138-74-4702
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~C:FY Poughquag
D. STREET ADDRESS 19 Bush Creek Ln.
12570
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCCRPORATED VILlAGE? D YES ~ NO
13.A. AGE 33 13.B.DATEOFBIRTHJune /29 /1967
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION
Quality Insurance Manager
Leine!"
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Pa terson , New Jersey
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
Johnny E. Mack
USA
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME Lula B. Pe terson
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE
First
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(21 = DEATH
(3) [] ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES ::J NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
r
I 'mpediment exists
Sept. 28.2000
by New York Domestic
25. B. SOLEMNIZA TlON PERIOD
ENDS AT MIDNIGHT ON:
TIME
YEAR
MONTH DAY YEAR
MONTH
DAY
ZIP
AM
2 : 00 PM
11 27
00
09
29
l~L
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~tJ'
C. LOCATION OF CEREMONY , (J*'
(CHECK ONE AND SPECIFY) . ./
D CITY OF D TOWN OF ct'VILLAG~ Il
SPECIFY ~IfJ1t'A4~.
NAME (PRINT)
SIGNATURE ~
E