179
STATE OF NEW YORK I STATE FILE NUMBER I
Dutchess (THIS SPACE FOR STATE USE ONL Y)
COUNTY DEPARTMENT OF HEALTH
~ ~fv fTO~1N Wappinger
DISTRICT 1368 AFFIDA VIT, LICENSE and ~ o/J-If/~lJ
NUMBER
REGISTER 179 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ..J
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME ~le S. Cha~man 11. A. FUU NAME FredA T~lor
FIRS MIDDLE CUR ENT SURNAME FIRST MIDDLE CU ENT SURNAME
~
'Z to-
~~ s:
~.;t <
0..-1 C
s~~u:
~ :5u..
00 -'
Z53~<
o z
;:; ~
ii ~
~ t:
$ eu
a: Q)
w >
~ Q)
"00
J.j
I-l
. ::l
~o
uU
'"
;:;",
ffi 0
() 0
~ ~
w C::a:
:I: I-l w
:;: C1l ~
ill ~~
a: 0
ooz
~N~
>- ,......~
~ ~cr
..: >-
w (J)
Q.
00
z:i:z
2~g W
~Ii~ ~
~~~ 0
~~~ u..-
zOO
Su. ;::
130 Ii:
~ ~ W
woO
I- on
i ;!;
1ST 0 0 1ST
2ND 0 [J 2ND
3RD 0 C 3RD
4TH 0 0 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is tru
as to my right to enter into the ma 'a e s . , _
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in ew 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 ITY LERK 25. A. SOLEMNIZATION PERIOD BEGINS
ine H. Snowden, Town Clerk
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 130-54-0481
D. SOCIAL SECURITY NUMBER __ _ _ ____
2 RESIDENCE A. (~i\-EY land B. Iku~~r
c. CHECK ONE 0 CITY [jC TOWN 0 VILLAGE
~~~CIFY Severn
1720 Barnwood Crt.
ZIP
21144
Arundel
D. STREET ADDRESS
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE ?'i 3B.DATEOFBIRTH 0('1- /?? /lQ7l.
MONTH DAY YEAR
4. EMPLOYMENT
w
>-
<(
>-
(J)
A. USUAL OCCUPATION Network Engineer
B. TYPE OF INDUSTRY OR BUSINESS Group One Sof tware
5. PLACE OF BIRTH POltl1hkE!enRip, Npw York
(CITY. STAT~OUNTRY iFNOT USA)
6. FATHER
A. NAME
Kenneth Y. Chapman
USA
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Cheryl Thomas'
USA
8. NUMBER OF THIS MARRIAGE
First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (31 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [J YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF OECREE PLACE ISSUEO AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
w
en
z
w
o
::i
~
{ SEAL }
'-v-I
NAME (PRINT)
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Cha pman
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 424-11-0303
12. RESIDENCE A. MArvl ::Inn B. Anne Arllnnp 1
1S'!'ATE)"" (COUNTY)
C. CHECK ONE 0 CITY}{J TOWN [J VILLAGE
~~CiFY Severn
D.STREETADORESS 1720 Barnwood Crt. ZIP 21144
E_ . IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES iXI NO
13. A. AGE ? 7 13.B. DATE OF BIRTH M::l l"(' h / OF, /1973
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Customer Service Rep.
B. TYPE OF INDUSTRY OR BUSINESS NAS
1S. PLACE OF BIRTH A 1 i (' pvi 11 p..._ A 1 ::l h::lm::l
(CITY, STATE/COUNTRY IF NUT USA)
16. FATHER
A. NAME Roya 1 McMnll en
B. COUNTRY OF BIRTH USA
17. MOTHER
A_ MAIDEN NAME Emma G. TAylor
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE F i r s t
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HeW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
31 0 ANNULMENT
/ /
(21 i:::: DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? !J YES [J NO
20. iF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEARI (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
c
~
c
c
C
[J
22. SIGNATURE OF BRIDE ~
, us
/~~puty Town Clerk
by New York Domestic
25. B. SOLEMNlZA TJQN PERIOD
ENDS AT MIONIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE ANO AT THE TIME ANO
PLACE INDICATED.
DATE
NY 12590
ATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 D OTHER, SPECIFY
09 23 00 11 21
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY .I}/7CH'~~<;
4-
c(,
tv1q". ;/\
~:--?
,
ZIP
AM
12: 15PM
00
1 = CIVIL
vt./
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Jt TOWN OF 0 VILLAGE OF
SPECIFY tv ~ ~ /-/ / # (,.;../'{ R.