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COUNTY
C.OWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tony L.
FIRST MIDDLE
I STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
j// qjJ1/pO@
Lo SUPPLEMENTAL FILE -.J
Dutchess
Wappinger
1368
142
FROM THE BRIDE
Crystal L.
FIRST MIDDLE
Pine
CURRENT SURNAME
1. A. FULL NAME
Ostrander
CURRENT SURNAME
11. A. FUll NAME
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER
New York
\STATE~
= CITY ~ TOWN
Wappinger
37G Alpine Dr.
108-56-3123
2. RESIDENCE A.
B. Dutchess
(COUNTY)
C VILLAGE
C CHECK ONE
AND
SPECIFY
ZIP 12590
. D. STREET ADDRESS
E. IS RESIDENCE WITHiN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/12 /1973
YEAR
Oct.
13. A. AGE 26
13.B. DATE OF BIRTH
3. A. AGE
26
Nov.
MONTH
14. EMPLOYMENT
3B. DATE OF BIRTH
MONTH
DAY
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Homemaker
CaieTYPE OF INDUSTRY OR BUSINESS TJnemp loyed
15. PLACE OF BIRTH Poughkeepsie New York
(CITY, STATE COUNTRY IF NOT USA)
UJ
I-
<
l-
ll)
A. USUAL OCCUPATION Cons truc tion
B. TYPE OF INDUSTRY OR BUSINESS Mid-Wes tchester Lana
5. PLACE OF BIRTH Poughkeepsie New York
ICITY. STATEiCOUNTRY IF NOT USA)
16. FATHER
A. NAME
Robert Pine
USA
6. FATHER
A. NAME Harry L. Ostr.ander
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Nancy Ann Bacon
USA
Elizabeth Ann Traver
USA
First
B. COUNTRY OF BIRTH
First
18. NUMBER OF THIS MARRIAGE
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE =ND? 31 = DIVORCE (31 0 ANNULMENT (21 C SE.~ TH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSEIS) ALIVE? = YES :: NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATiCN
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) CITY. STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (31 = DIVORCE 31 = ANNULMENT 21 = S=.-\TH
C. DATE LAST MARRIAGE ENDED? / /
'.4ONTH JAY YEAR
D. ARE .~NY FORMER SPOUSE,SI ALIVE? = YES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. "ROVIOE ;HE FOLLOWING INFORMATiON
DATE OF DECREE PLACE iSSUED AGAINS, 'NHOM
"MONTH. DAY. YEAR) (CITY STATEiCOUNTRY. IF NOT USA! SELF SPOUSE
1ST ~ 1ST
2ND 2ND
3RD 3RD
4TH G 4TH
I, being duly sworn, depose and say, that to the best of my knowleoge and belief that the information I provided is true a
as to my right to enter into the ~iage S I
21 . SIGNATURE OF GROOM ~
nt eXists
RENT N
ATE Aug. 23,2000
by New York Domestic
Town
W
en
z
W
o
::::i
23. SUBSCRIBED AND SWORN ,0 BEFOR
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 911 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 RK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME \PRINT) Ela. e Snowden, Town Clerk
SIGNATURE ~ DATE 8/23/00
MAILING ADDRESS
PO Box 324 NY 125 0
STR ET S AT
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON ,HE
DATE AND AT THE TIME AND
PLACE INDICATED.
10
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-.--I
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
ZIP
8: 55 AM
PM
08
24
00
1~IL
A. STATE NEW YORK B. COU
OTHER. SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
LJ CITY OF ~WN OF C VILLAGE OF
SPECIFY
tAJA."J Ms'ltl
NAME (PRINT)
SIGNA TURE ~
DOH-9B (1198)
SIGNATURE ~