168
~
o
0'1
l1'\
N
~
~
,...
Ow
><....
<
)lii
CIl
Z
!z~ ~
w.-l :;:
:Cll <(
~~ Q
SmW-u.
o ,... ~
ili CIl =! U.
~s:~<(
!;(~g
~ ~
a Cll ()
:l!~
w
Cl .
:!O'C
~~
't;
:~
itJ
Itll
~fIl
- s:
!!, CIl
lr~
W tJ
U tll
:l!::c
W a:
i )::l
:i CIl ~
wZz
a: 0
gO'l~
~::E
... a:
~ t;
ll.
Ul
ii~ W
~l~ ~
Iii w Z ....
~i! ~
.... f?~ w
'1i; u
COUNTY
Ot&/TOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF~NEW~.ORK:~~[..;.,
.DEPARTMENTOF.HEALTH' .;;~;: :.:if':(\:
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert
FIRST
Clark
CURRENT SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE OM Y)
I
;, .,;,- .' ~
nllrnpl':l':
W:lpping"'"
1368
168
c ~~'::, '
-,".
.})'
;';
L 0 SUPPLEMENTAL FILE
~
1. A. FULL NAME
IL
MIDDLE
FROM THE BRIDE
11. A. FULLNAME F~$tty -\ltlDUE
B. BIRlli NAME (MAIDEN NAME), IF DIFFERENT K e t c h
C. SURNAME AFTER MARRIAGE Gillespie
(OPTIONAL, SEE REVERSE) 367 -4 4 - 7729
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(ST A TE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VIlLAGE
~~CIFY Wappinger
D. STREETADDRESS 119 New Hackensack Rd. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCDRPORA TED VILLAGE? 0 YESJt] NO
13.B.DATEOFBIRTH Dec. /29 /1942
MONTH DAY YEAR
~i llUiBifrj
CURRENT U A 8
0-
N
B. BIRlli NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W i
SPECIFY app nger
o. STREET ADDRESS 119 New Hackensack RciJp 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [jC NO
3.A.AGE45 3B.DATEOFBIRTH Mav /10 /1955
MONTH DAY YEAR
13. A. AGE
57
311-58-5531
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Con Edison
5. PLACE OF BIRTH Indianapolis. Indiana
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINES~ Unemployed
15. PLACE OF BIRTH Niles. Michigan
(CITY, STATEiCOUNTRY IF NOT USA)
16. FATHER
A. NAME Jerry Ketch
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Avis C. Moore
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE See ond
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
DEATH
6. FATHER
A. NAME Harlan E. Gillespie
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Virginia R. Goll
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE
Second
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
DEATH
B. HOW DID LAST MARRIAGE END? (3~ IllVoRCE (3) 0 ANNULMENT (2) 0 DEAlli
C. DATE LAST MARRIAGE ENDED? Oct. /02 /1997
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEtCOUNTRY, IF NOT USA) SELF SPOUSE
10/02197 La Porte Co. Indiana JtJ 1ST
o 2ND
o 3RD
o 4TH
belie that the infonnatlon I prov; e
1ST
2ND
3RD
4TH
I, being uly sworn, depose
as to my right to enter into
B. HOW DID LAST MARRIAGE END? (3J'(J DIVORCE (3) 0 ANNULMENT (2) 0 OEA lli
C.DATELASTMARRIAGEENDED? Feb. /13 /1990
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 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
2/13/90 Berrien Co. Michigan 0
o
o
21. SIGNATURE OF GROOM ~
w
en
z
w
u
::::i
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 na ed V by any person authorized by New York
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID I NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the u of a second or subsequent ceremon ,
~ 24. TOWN OR CITY CLERK . 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRI~ Elaine H . Snowden, Town Clerk .'
{SEAL SIGNATURE nf2 JI1 1 \.\ ~te<<.. DATE 9/12/00 TIME MONTH DAY YEAR MONTH DAY
~ILlNG ADDREss. 10: 0.5AM 09 13 00 11 11
"-v-I l' .O.Box ;j24 Wa in ers Falls New York 1259 PM
I
00
o
25. B. SOlEMNIZATION PERIOO
ENDS AT MIDNIGHT ON:
YEAR
I CERTIFY THAT I SOlEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
27. TYPE OF CEREMONY
o p( RELIGIOUS 1 0 CML
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ti+C.{,{(
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF lff TOWN OF 0 VILLAGE OF
SPECIFY t,Y/'1j..r .:
26, SOLEMNIZATION OCCURRED
29. OFFICIANT
NAME (PRINT)
/?e rrt.~" d
()c.k.6,r (; I Zcoo
TITLE
NAME (PRINT)
SIGNATURE ~
OOH-98 (1198)
NAME (PRINT)
SIGNATURE ~
t/