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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
A nthn~~Lyh ri~tnrh~u~R~QDlt'AME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368
~~~I~~~R 1 08
1. A. FULL NAME
FIRST
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B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 090-52-3384
2. RESIDENCE A. NV B. nlltr.hp.~~
iSr ATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY W~rringer~ F~lIs
D. STREET ADDRESS 38 A Franklindale Ave ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VilLAGE? r( YES 0 NO
3. A. AGE 54 3B. DATE OF BIRTH OR / n~ / 1 Q~R
MONTH DAY YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION S~fp.ty nffir:p.r
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH North T~rrvtown. New York
(CITY. STATE / couNfRY IF NOT USA)
6. FATHER
A. NAME Mario r.nntp.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ros~lie Ruth Greenfield
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) D'1>IVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 06/ 02 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? O~ES 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
06/02/2010 Poughkeepsie, New York
DEATH
o
(2) 0 DEATH
2010
YEAR
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I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONl Yi
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ann Baxter Paschal
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Contp.
(OPTIONAL - SEE REVERSE) 81
D. SOCIAL SECURITY NUMBER 242-08-8 7
12 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VilLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 38 A Franklindale Ave ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VilLAGE? ~ YES 0 NO
/22 /1963
DAY YEAR
13B.DATE OF BIRTH
01
MONTH
13. A. AGE 47
14. EMPLOYMENT
A USUAL OCCUPATION Office Support
B TYPE OF INDUSTRY OR BUSINESS Guilford County Schools
15. PLACE OF BIRTH Greensboro. North Carolina
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Baxter Leon Paschal
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Virginia lola Earl
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) c::rbIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 23 / 2009
MONT~ DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? LJYES 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
09/23/2009 Guilford County. N.C r:t
DEATH
o
YEAR
24
2010
10
22 2010
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY Pu t c.h.~<
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY Po /,I,l." ~ I( "- ~ bL! (':e...
1:7 ,
NAME (PRINT)
SIGNATURE~