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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Clinton
FIRST MIDDLE
COUNTY
6t*rrOWN
DISTRICT
NUMBER
REGISTER
NUMBER
!
Dutchess
Wappinger
1368
138
1. A. FULL NAME
Nicholas
CURRENT SURNAME
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SDCIAL SECURITY NUMBER
2 RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN jC VILLAGE
~~~CIFY Wappingers Falls
o STREETADDRESS 17 Gilmore Blvd. Nort~p 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 38 38. DATE OF BIRTH Al'ril / 04 /1962
MCNTH DAY YEAR
073-60-7913
4. EMPLOYMENT
A. USUAL OCCUPATION
Sales
B. TYPE OF INDUSTRY OR BUSINESS Heart Acura
Manhattan New York
(CITY, STATE/COUNTRY IF NOT USAI
5. PLACE OF BIRTH
6. FATHER
A. NAME
Clarence
USA
Castle
B. COUNTRY OF BIRTH
7. MOTHER
Constance
USA
B. NUMBER OF THIS MARRIAGE Second
L. Nicholas
A. MAIDEN NAME
8. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
DEATH
B HOW DID LAST MARRIAGE END? (31 ~ DIVORCE (3) 0 ANNULMENT 121 0 DEATH
C. DATE LAST MARRIAGE ENDED? March /17 /2000
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES r:J 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
3/17/00 Dutchess Co. NY 0 ~
w
en
z
w
o
:::::i
I
I
STATE FILE HUMBER
(THIS SPACE FOR STATE USE ONLY)
~ ~')DloD
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Susan G.
FIRST MIDDLE
~
Charles
CURRENT SURNAME
11. A. FULL NAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Char Ie s
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 130-56-9630
12. RESIDENCE A. New York B. Du tchess
(STATEI (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN:ltJ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 17 Gilmore Blvd North
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 34 13.B. DATE OF BIRTH Dee.. /
MCNTH
ZIP 12590
~YESDNO
18 /196'J
DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Administrative Asst.
B. TYPE OF INDUSTRY OR BUSINESS Pr ime F inanc ial S e r .
15. PLACE OF BIRTH Siparia, Trinidad
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
Winston D. Charles
Grenada
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME Laurel G. Harris
B. COUNTRY OF BIRTH Trinidad
18. NUMBER OF THIS MARRIAGE Third
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
Two
DEATH
B. HOW DID LAST MARRIAGE END? 131:19 DIVORCE ,31 C ANNULMENT (21 0 DEATH
C. DATE LAST MARRIAGEENDED? July /16 /1998
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES = NO
20. 'F PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUEO AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
3/18/92 Bronx. NY = ~
7/16/98 Dutchess Co. NY ~
~
DATE Aug. 16.2000
by New York Domestic
25. B. SOlEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
YEAR
00
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ,Vu,!cL"J(S