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COUNTY
~~ITOWN
DISTRICT
NUMBE'l!
REGISTER
NUMBER
STATE OE.:t,lEW :YOFlJ<~.(_r-
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Shaun Patrick
FIRST MIDDlE
Weitlich
CURRENT SURNAME
STATE flU: _BI:II
(THIS SPACE FOR STATE USE ON/.. Y)
Dutchess
Wappinger
1368
104
.JY.k ...d V I 0 ()
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dana Merry
FIRST MIDDLE
1 . A. FULL NAME
Baxter
11. A. FULL NAME
CURRENT SURNAME
Q.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Baxter
(OPTIONAL - SEE REVERSE) 082 68 0793
D. SOCIAL SECURITY NUMBER - -
12. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~CIFY Wappingers Falls
o STREET ADDRESS 22 Prospect Street ZIP 12590
B BIRTH NAME, IF DIFFERENT
c. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A New York
(STATE,
C CITY C TOWN ~ VILLAGE
Wappingers Falls
D. STREET ADDRESS 22 Prospect Street
108-56-4381
B. Dutcress
(COUNTY)
C. CHECK ONE
AND
SPECIFY
12590
ZIP
E. IS RESIDENCE WITHiN UMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
/ 19 / 1974
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Xl YES 0 NO
Dec. /11 /1978
MONTH DAY YEAR
21
3. A. AGE
25
July
MONTH
14. EMPLOYMENT
13.B. DATE OF BIRTH
3B. DA TIE OF BIRTH
13. A. AGE
4. EMPLOYMENT
A. USUAL OCCUPATION Full Time Student
B. TYPE OF INDUSTRY OR BUSINESS Culinary Ins t. of Amer
5. PLACE OF BIRTH Beacon, New York
(CITY. STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Full Time Student
ca B. TYPE OF INDUSTRY OR BUSINESS Culinary Inst. of AmericiC
15. PLACE OF BIRTH pou~hkeeEsie. New York
(CITY, STATE/COUNT IF NOT U AI
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Gail Thornton
USA
First
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME Anita Hurley
B. COUNTRY OF BIRTH Nova Scotia
8. NUMBER OF THIS M~RRIAGE First
Arthur Baxter
USA
Alan Weitlich
USA
18. 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 END? 13) [J DIVORCE 13) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
121 C DEATH
B. HOW DID LAST MARRIAGE END? (3) C DIVORCE
C. DATE LAST MARRIAGE ENDED?
31 .J ANNULMENT
/ /
12) = DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(Sl ALIVE? = YES '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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? == YES = NO
20. iF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE -HE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
,MONTH. DAY. YEAR) (CITY. STATe,COUNTRY, IF NOT USA) SELF SPOUSE
w
en
z
w
o
::i
1ST::J '- 1ST 0
2ND ::J 2ND 'J
3RD :::J 3RD 0
4TH :....J 4TH n
I, being duly sworn, depose and say, that to the best hf y knowledge and belief that the Information I prOVided IS true and that I declare mat no legal Impediment eXists
as to my fight to enter Into the marna~ state. 4-- ~ 0 '() 01 /J
21 SIGNATURE OF GROOM ~ . ~ ~ 22. SIGNATURE OF BRIDE ~n (1.. C i::X .J....cJI......
USE CURRENT _ U~RRE"'T NAME
23 SUBSCRIBED AND SWORN TO BEFORE ME Depu ty Town Clerk J ne 27 2000
SIGNATURE OF TOWN OR CITY CLERK ~ DATE U ,
This license authorizes the marriage in New York tate of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
n 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) Elaine Town Clerk
SIGNATURE ~ DATE 6/27/00
MAILING ADORE
P.O. Box in ers Falls NY 12590
STREET CITY WN A
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME DAY YEAR o!>t RELIGIOUS
DATE AND AT THE TIME AND \1' 30 "\ CO
PLACE INDICATED 'PM \ - '-\ - '9 C OTHER. SPECIFY
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT DN,
~
{ SEAL }
'-..-'
MONTH
DAY
YEAR
MONTIH
DAY
YEAR
TIME
AM
2: 15 PM
6
28
00
8
26
00
28. PLACE WHERE MARRIAGE OCCURRED
, = CIVIL
A. STATE NEW YORK B COUNTY i')A1l::hes.S
29. OFFICIANT\;? ~ \.. _ I \ . \. \. \' <
NAME (PRINT) P V . . \"-\ t-Of\ '-. W \ · a.IM ~
SIGNATURE~~\l ~~d.W~')
MAILING ADDRESS
E l~ S\r..tet ,,~ NQ. Wa~'N1"A
STREET CITYITOWN \
30. W ESS TO CEREMONY
-'"
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TITLE "'?a."" tor
DATE "\, ~ {:f;
~l\s. N Y
SlATIE
o CITY OF :] TOWN OF .~ VILLAGE OF
SPECIFY Wa~~ ~ \ \s
NAME (PRINT)
SIGNATURE~
DOH-ll8 (111ll8)
NAME (PRINT)
SlGNATURE~
",.