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8T A TE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Martin C.
1ST
2ND
C 3RD
'-' 4TH
nd belief that the information I provided is true an
COUNTY
I. rvfTOWN
asTRICT
1lllJMBEH
REGISTER
NUMBER
Dutchess
Wappinger
1368
158
23. SUBSCRIBED AND SWORN TO BEFO ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York ate 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
{ } NAME (PRIN~Elaine H0 Snowden, Town Clerk TIME MONTH DAY YEAR
SEAL SIGNATURE ~'H..J U. ~ DATE 9/7/00
1,k\J.L.IN(3. ADDR . AM
~ ~U tlox 4, Wa in ers Falls, NY 12590 3:30 PM 9 8 00
STR ET ITY WN A 21P
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME DAY Y R
DATE AND AT THE TIME AND
PLACE INDICATED.
I. A. FULL NAME
Miller
FIRST
MIDDLE
CURRENT SURNAME
a.
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Du tchess
(STATE) (COUNTY)
= CITY ~ TOWN 0 VILLAGE
Wappinger
o STREET ADDRESS 9 Peggy Lane
096-44-2216
C. CHECK ONE
AND
SPECIFY
12590
ZIP
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 42 3B. DATE OF BIRTH Aug. / 8 /1958
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION General Contractor
B. TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Floyd Miller
USA
Elizabeth Mullen
USA
Third
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
Two
DEATH
B. HOW DID LAST MARRIAGE END? (3) ex DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? May / 4 /2000
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. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
11/18/86 Poughkeepsie, NY ~ ~
5/4/00 Goshen, New York ~
w
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::;
I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE O/I/L Y)
~'1}~V){)O
Lo SUPPLEMENTAL FILE ~
FROM THE BRIDE
11. A. FULL NAME Susan M. Michael
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Brown
c. SURNAME AFTER MARRIAGE Miller
(OPTIONAL. SEE REVERSE) 096-52-5981
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
o CITY ~ TOWN 0 VILLAGE
C. CHECK ONE
AND
SPECIFY
Wappinger
9 Peggy Lane
ZIP
12590
D. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Xl NO
13. A AGE 42 13.B. DATE OF BIRTH April /25 /1958
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Registered Nurse
B. TYPE OF INDUSTRY OR BUSINESS Putnam Hospital
15. PLACE OF BIRTH North Tarrytown, New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Frank Brown
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Mary Alice
USA
Second
Biglan
lB. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
DEATH
B. HOW DID LAST MARRIAGE END? (3) 00 DIVORCE (31 = ANNULMENT 2' _ DEATH
C. DATE LAST MARRIAGE ENDED? Feb. / 10 /1989
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? Xl YES = 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
2/10/89 Dutchess County, NY ~
eXists
DATE Sept. 7, 2000
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
11
6
00
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY ~
(CHECK ONE AND ECIFY)
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