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STATE OF:...NEWYORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert J.
FIRST MIDDLE
o L... 1ST 0 0
o . . 2ND 0 0
o 3RD C C
o L 4TH 0 D
:tno~ge and bel' f that the information I provided is true.~d 1hat I declare th~~ no~al impediment exists
~~"t . 22. SIGNATURE OF BRIDE ~ r~..<. /(. I c..-'CtLA-U-../
E CU RENT NA \ USE CURRENT NAME
Deputy Town Clerk
23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta 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 urpose of a second or subsequent ceremony.
24. TOWN OR CLERK 25 A SOLEMNIZATION PERIOD BEGINS
aine H. Snowden, Town Clerk . .
TIME
DATE 6/19/00
NY 12590
, .COUNTY
~. *ITOWN
. ISTRICT
IMBER
R"ISTER
NUMBER
Dutchess
Wappin~er
1368
95
1. A. FULL NAME
Florkowski
CURRENT SURNAME
..
N
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER
New York
(STATEI
C. CHECK ONE C CITY Xi TOWN 0
~~~CIFY Union Vale
o STREET ADDRESS 31 Jennife~ Hill ~~i ZIP
E. IS RESIDENCE WITHiN LIMITS OF CITY OR tNc~RP~~Th~~t1GE? e 0
3. A. AGE 62 3B. DATE OF BIRTH April / 18
MONTH DAY
2. RESIDENCE A.
128-28-5975
B Dutchess
(COUNTY)
VilLAGE
12540
YES IX NO
/1938
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION
Retired
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Yonkers. New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Michael Florkowski
B. COUNTRY OF BIRTH USA
7. MOTHER Frances Bakowski
A. MAIDEN NAME
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE
Second
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
One
B. HOW DID lAST MARRIAGE END? (3) C DIVORCE (3) 0 ANNULMENT (2) IX DEATH
C DATE LAST MARRIAGE ENDED? Nov. / 5 / 1988
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? :J YES ~ NO
10. IF PREVIOUSLY OIVORCED OR ANNUlED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEARl (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
21. SIGNATURE OF GROOM
w
fJ)
Z
W
o
:::i
~
{ SEAL }
'-v-I
NAME (PRINT)
Wappingers Falls,
I WN
26. SOLEMNIZATION OCCURRED
TIME M AY YEA
A
27. TYPE OF CEREMONY
o ~OUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED.I1 1 ..
A. STATE NEW YORK B. COUNTY Cj'f V~
c.
S RE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
I
STATE FILE HUMBER
(THIS SPACE FOR STATE USE ONLY)
I
/ tJl<v~~j)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Patricia R.
-1
Pettersen
11. A. FULL NAME
CURRENT SURNAME
Thompson
Pettersen
105-30-6865
Dutchess
FIRST
MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B.
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
~~~CIFY Union Vale
o STREETADORESS 31 Jennt~~~a~H~~!~e ZIP 12540
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORA'fED VILlAGE? 0 YES ~ NO
13.A.AGE 64 13.B.DATEOFBIRTHMarch /12 /1936
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION
Retired
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH New York City, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
John Thompson
USA
Elsie Back
USA
Second
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
One
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE ,3) 0 ANNULMENT (2) 00 DEATH
C. DATE LAST MARRIAGE ENDED? May / 23 / 1987
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES Xi NO
20. 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
DATE
June 19, 2000
by New York Domestic
MONTH
YEAR
MONTH
YEAR
9:45
AM
PM
6
20
00
8
18
00