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~~~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JotmD~incent H'%~~T SURNAME
23. SUBSCRIBED AND SWORN TO/AFFIR
SIGNATURE OF TOWN OR CITY Cl
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
/"""'"\ ---
TITLE i().<..~ ),,51 ( C r
X. g-Olol<.J
r~
COUNTY Dlltches~
CITYITOWN W~rrinOF!r
~~~:~c; 13RR .
~~~~~~R 84
1 . A. FUll NAME
FIRST
Q.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER OR7 -~4-Q4?O
2. RESIDENCE A. NYsTATE) B. qM!ffWSS
C. CHECK ONE 0 CITY.,!lJ TOWN 0 VilLAGE
AND
SPECIFY Lagrangj:>
D. STREET ADDRESS 1 O? ~Ieight Plass Rd ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
n" / ~n /1942
MOl'll'R ~:r YEAR
....
:;:
c:c
c
wU:
"LL
ic:c
3. A. AGE 68
4. EMPLOYMENT
A. USUAL OCCUPATION Department McmaOF!r
B. TYPE OF INDUSTRY OR BUSINESS I RM
5. PLACE OF BIRTH rcl~l. ~A~E~~:ur,.~fFNO~YsA)
6. FATHER
A. NAME Herbert Joseph HaiOht
B. COUNTRY OF BIRTH I J ~ A
3B. DATE OF BIRTH
7. MOTHER
A. MAIDEN NAME M~rinn Thp.resa Brown
B. COUNTRY OF BIRTH I J ~ A
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
1
(2) ~ DEATH
2002
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? O~/ 16 /
MONTH pAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ['!"'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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to t
as to my right to enter into the marrrage at
21. SIGNATURE OF GROOM~
~
{ SEAL}
'-r-"
NAME (PRINT)
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-9B (09/2009)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
11. A. FUll NAME FIRST C ~1~rilJ'1 Lee H a iJuRRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTMorse
C. SURNAME AFTER MARRIAGE H a ig ht
(OPTIONAL - SEE REVERSE)127 50 9339
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE ANY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
~~~CIFY Wappinger
D. STREETADDREss15 Hamilton Rd
ZIP 12590
o YES~ NO
%956
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIllAGE?
13. A. AGE54 13BDATE OF BIRTH 01 ~O
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Court Clerk
B. TYPE OF INDUSTRY OR BUSINESS Municipality
15. PLACE OF BIRTH Beacon. Ny
(CITY. STATE 1 COUNTRY IF NOT USA)
16. FATHER
A. NAMEJason Morse
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Gloria Phillips
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
1
(3) 0 ANNULMENT (2) ~ DEATH
/ 2002
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED? 09 / 01
MONTH .J.DA Y
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES CJ 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
o 1ST
o 2ND
o 3RD
o 4TH
at the information I provided is tru
o
o
o
o
nt exists
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
03:06PM
2010
07
15
09
12 2010
~ CIVil
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNY 70vltJcS
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF JI('TOWN OF 0 VilLAGE OF
SPECIFY L 1'1 61"/ A III (;. ('
STATE
NAME (PRINT)
SIGNATURE~