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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY
CITYiTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gerett R.
FIRST MIDDLE
Hughes
CURRENT SURNAME
Dutchess
Waopinszer
1368
139
/~I r~)cO
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tracy L.
FIRST MIDDLE
-1
, A. FULL NAME
Yocum
CURRENT SURNAME
1 1. A. FULL NAME
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME IMAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B Dutchess
(STATE) . ,COUNTY)
o CITY Xl TOWN 0 VILLAGE
Wappinger
D. STREET ADDRESS 29F Sherwood Forest
161-58-9384
Yocum
061-70-4622
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER
2. RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE = CITY ~ TOWN 0 VILLAGE
AND W.
SPECIFY app~nger
D. STREET ADDRESS 29F Sherwood Fores t ZIP 12590
E. IS RESIDENCE WITHiN liMITS OF CITY OR INCORPOAA TED VILLAGE? 0 YES i!S NO
3B. DATE OF BIRTH March / 5 /1974
MONTH DAY YEAR
C. CHECK ONE
AND
SPEC IFY
12590
ZIP
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? :J YES Xi NO
13.B.DATEOFBIRTH Sept. /24 fi969
MONTH DAY YEAR
3. A. AGE
26
13. A. AGE
30
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Generalist
B. TYPE OF INDUSTRY OR BUSINESS Chubb Computer Institute
15. PLACE OF BIRTH (CITY, sr,,~E/~8u~~~~~~u~' New York
16. FATHER
A. NAME John William Hughes
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS Micrus
5. PLACEOFBIRTH Camp Hill, Pennsylvania
ICITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Gerald Yocum
USA
Jo Ellen Babb
USA
B COUNTRY OF BIRTH
Kathleen Krispien
USA
First
First
18. NUMBER OF THIS MARRIAGE
8. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
JEATH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? 131 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
131 :::J ANNULMENT
/ /
(2) C DEATH
B. .,OW DID cAST MARRIAGE END? (3) '= DIVORCE
C. JATE L~ST MARRIAGE ENDED?
31 = ANNULMENT
/ /
2 = DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSEIS) ALIVE? = YES = NO
10 IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) 'CITY. STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
MONTH JAY vEAR
D. ARE ~NY FORMER SPOUSE(S) ALIVE? = YES = NO
20. iF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFCP.MATION
DATE CF DECREE PLACE ISSUED AGAINST WHOM
MONTH JAY. YEAR) (CITY, STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
1ST :::J 1ST
2ND :J 2ND
3RD :J 3RD
4TH ~ 4TH
I. being duly sworn, depose and say, that to the best of my knowledge and belief that the Information i provided is true
as to my right to enter into the marri,~ state. ~
21. SIGNATURE OF GROOM ~ ~. n
Town
w
en
z
w
o
::::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in ew York Stat of the bride and groom named above by any person authorized
Relations Law ~ 11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME IPRINT)~ine ~. S~den, Town Clerk
{SEAL SIGNATURE~ AII1D_\~~l"^,c!a-. DATE 8/17/00 TIME MONTH DAY YEAR
MAILING ADORE 8 : 4 5 AM
'-v-I PO Box 324 Wa in ers Falls NY 12590 PM 8 18 00
R I A P
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER~ ~
SONS NAMED ABOVE ON THE 1M AY Y 0 ~ RELIGIOUS
~tl~E ~~gl(;:TJ~E TIME AND 2.. $0 ~ Lou> 90 OTHER, SPECIFY
10
16
00
by New York Domestic
25. B. SOLEMNIZATlON PERIOD
ENDS AT MtONIGHT ON:
MONTH
DAY
YEAR
1 = CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY,>>(;rC:He~,:;
TITLE ~ y !)k ,'Cop,.1
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF I TOWN OF l( VILLAGE OF
SPECIFY WA f'p I NQ i R..$ Fac..c..~
ZIP
31. WITNESS TOfFREMONV
NAME (PRINT)
SIGNATURE ~