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2:..._
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Dale
FIRST
I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONL Y)
~oll~/v7)
. I
Lo SUPPLEMENTAL FILE ~
COlJlol1Y Dutchess
CITYfTOWN Wappinger
2~~:~c: 1368
~3~lgJ~R 183
FROM THE BRIDE
Elizabeth Doris
FIRST MIDDLE
VanDemark
CURRENT SURNAME
Montgomery
CURRENT SURNAME
11. A. FULL NAME
MIDDLE
B. BIRTH NAME :MAIDEN NAME), IF DIFFERENT Hun t
c. SURNAME AFTER MARRIAGE Montgomery
(OPTIONAL' SEE REVERSE) 071-38-0334
D. SOCIAL SECURITY NUMBER
12 RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
o CITY Ki TOWN 0 VILLAGE
0-
N
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
o CITY ~ TOWN :::J VILLAGE
Wappinger
D. STREET ADDRESS 145 Chelsea Road
294-62-1560
C. CHECK ONE
AND
SPECIFY
Wappinger
145 Chelsea Road
C. CHECK ONE
AND
SPECIFY
12590
ZIP 12590
o YES ~ NO
29 /1956
YEAR
ZIP
D. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? c.. YES Xi NO
13. A. AGE 52 13.B. DATE OF BIRTH Oct. / 28 / 1947
MONTH DAY YEAR
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A. AGE 43 3B. DATE OF BIRTH Sept. /
MONTH
DAY
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION COlIUllunity Resident Aide
B. TYPE OF INDUSTRY OR BUSINESS State of New York
15. PLACE OF BIRTH Wappingers Falls. New York
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Welder
B. TYPE OF INDUSTRY OR BUSINESS Union 350
5. PLACE OF BIRTH Chillocothe, Ohio
(CITY, STATE/COUNTRY If NOT USA)
16. FATHER
A. NAME
Arthur Hunt
USA
6. FATHER
A. NAME Esaw Montgomery
8. COUNTRY OF BIRTH USA
7. MOTHER
B. COUNTRY OF BIRTH
17. MOTHER
8. COUNTRY OF BIRTH
Annie Doris Soper
Newfoundland
18. NUMBER OF THIS MARRIAGE Second
A. MAIDEN NAME
Flossie Montgomery
USA
8. NUMBER OF THIS MARRIAGE Second
A. MAIDEN NAME
B. COUNTRY OF BIRTH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
One
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) _ ANNULMENT 2\ Xl DEATH
C. DATE LAST MARRIAGE ENDED? Aug. /6 / 1984
MONTH DAY vEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? eYES )t NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATE/COUNTRY. IF NOT USA! SELF SPOUSE
w
U)
Z
W
o
::i
25. B. SOLEMNiZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
9
26
00
11
24
00
1 [] CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY R~
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
29. OFFICIANT
NAME (PRINT)
:TlTLE pCt. s+-o-
DATE lol/3/~ 0
I '
/ lJQ
o CITY OF >( TOW~ OF 0 VILLAGE ~ )
SPECIFY JJ.1!:fI/'A. 'j( - (l. kP-ls..€ i.
STATE
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~
rVU..LCA 11IQSn