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STATE OF NEW YORK I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess DEPARTMENT OF HEALTH
CITYfroWN Wappinger AFFIDAVIT, LICENSE and
~IT~:kc; 1368 .
~5~1~~~R 85 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE --1
FROM THE GROOM FROM THE BRIDE
1. A. FUll. NAME Dan~L~eith Pett~^~WSURNAME 11. A. FULL NAME Michelle Ann Oldenbor~
FIRST FIRST MIDDLE CURRE SURNAME
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Pp.ttig raw
(OPTIONAL. SEE REVERSEb
D. SOCIAL SECURITY NUMBER 53-70-0914
12. RESIDENCE A NY BDutchess
(ST A TEl (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREETADDREss17 Twin Rd
ZIP 12590
o YES"tJ NO
;(980
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 071-66-0.485
2. RESIDENCE A. N'fsTATE) B. q~ess
C. CHECK ONE 0 CITY.,It] TOWN 0 VILLAGE
AND [') L..k .
SPECIFY rOUg11 eepsle
D. STREET ADDRESS 17 Twin Rei ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
Mol,Q / g~ / ~l9
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE~n 13B.DATE OF BIRTH 02 ,-(57
MONTH DAY
3. A. AGE 30
4. EMPLOYMENT
A. USUAL OCCUPATION Alarm Technician
B. TYPE OF INDUSTRY OR BUSINESS Hnmp. Rp.r.lJrity
5. PLACE OF BIRTH POI ~hkj:>p.rrsie N~
(CITY, ATE / cou TRY IF 'NOT SA)
6. FATHER
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Speech Pathologist
B. TYPE OF INDUSTRY OR BUSINESS WSCD
15. PLACE OF BIRTH Manhattan. Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEJohn Oldenborg
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Jane Dawson
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
A. NAME Michael Bruce Pettigrew
B. COUNTRY OF BIRTH I I R A
7. MOTHER
A. MAIDEN NAME Patricic Nnfi
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
,.
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
o
o
o
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23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE
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
NAME (PRINT)
DAY
YEAR
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
"-v-'
TIME
MONTH
YEAR
MONTH
TE 07/14/2010
ers Falls NY 12590
ITYIT WN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ~IVIL
\.\ O<J - 20\0 90 OTHER, SPECIFY
~
AM
03:34PM 07
2010
09
12 2010
15
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCU~.EDD \. \" " r (
A. STATE NEW YORK B. COUN~>~
C. LOCATION OF CEREMONY
.(CH~K ONE AND SPECIFY)
V= f\ 0 '~~ 0 ""^"'Q'
SPECIFY \,\J\)..! lef_~~\ ~
\"
SIGNATURE~