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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Timntj;)Kr~ntt I InrlJa~9~~NAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~f: 1368 .
~G~I~~~R 123
1 . A. FULL NAME
FIRST
0-
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 073-56-1104
2. RESIDENCE A. N~ B. nlltr.hA~~
( TATE) (COUNTY)
C CHECK ONE 0 CITY I!il'I' TOWN 0 VILLAGE
AND P hk .
SPECIFY nl19 AApSIA
D. STREET ADDRESS 14 Husky Hill Rd
ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES l!f NO
MONQ~ / 018 / y!~60
3. A. AGE 50
38. DATE OF BIRTH
....
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4. EMPLOYMENT
A. USUAL OCCUPATION Comml Jni~::!tinn 8. Sign::!1
B. TYPE OF INDUSTRY OR BUSINESS Metro North
5. PLACE OF BIRTH PAAkskill, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME EIISIMnrth F IlnrlArwnnrl
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Agnes Catherine McGuire
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
8. HOW DID LAST MARRIAGE END? (3) dDlVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 06/ 20 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? r::MES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 06/20/2002 Poughkeepsie. Ny d
~D 0
3RD 0
DEATH
o
(2) 0 DEATH
2002
YEAR
a:
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23. SUBSCRIBED AND SWORN TO/AFFI
SIGNATURE OF TOWN OR CITY C
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Diane Marie Van Winkle
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Underwood
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 066-74-1223
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREET ADDRESS 14 Husky Hill Rd ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/04 ,/'j 976
DAY YEAR
13. A. AGE ~4
01
MONTH
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Deli Clerk
B. TYPE OF INDUSTRY OR BUSINESS Food
15. PLACE OF BIRTH Mount Kisco. New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Alan Van Winkle
'8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Patricia Hecker
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
DATE
09/03/2010
This license authorizes the marriage in New York State 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 purpose of a second or subsequent ceremony.
24, TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
n
r-^-,
{ SEAL }
'-v-/
NAME (PRINT)
SIGNATURE ~
MAIL20 ~R
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
by New York Domestic
TIME
YEAR
MONTH
YEAR
MONTH
ZIP
AM
01 :33:>M
09
04
11
02 201 0
2010
STATE
27. TYPE OF CEREMONY
o ~LIGIOUS
9 0 OTHER, SPECIFY
10
TITLE 'L11e I<..#,'/I+ M llJi51 Gll..
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY W~{JI At GEYC
V;w 73otU~c
1;).,~?>3
NAME (PRINT)
SIGNATURE~
31. WITNESS TO
