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COUNTY DIItr.hA!=:!=:
CITYITOWN Wappinger
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
la~l~h';1 Victor P~C~~ENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
-.J
FIRST
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ta~n Elizabeth Stephens
FIRST MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
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N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Pa risi
(OPTIONAL - SEE REVERSE\, 05 76 4637
D. SOCIAL SECURITY NUMBER I - -
12. RESIDENCE ANY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
~~~CIFYWappinaer
D. STREET ADDRES~05 Popula Blvd
ZIP 12590
o YES'tJ NO
)985
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 fi-nn-3500
2. RESIDENCE A. NY B. [)llt~hA!=:!=:
-,sTATE) (COUNTY)
C. CHECK ONE 0 CITY llJ TOWN 0 VILLAGE
AND W .
SPECIFY ~rrlngAr
D. STREET ADDRESS 605 Popula Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES\{] NO
n? / O~ /1~R3
MO'!(ifH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE25 13B.DATE OF BIRTH 07 ~1
MONTH DAY
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3. A. AGE 27
4. EMPLOYMENT
A. USUAL OCCUPATION Nucle~r PI~:mt ()per~tnr
B. TYPE OF INDUSTRY OR BUSINESS IPEe
5. PLACE OF BIRTH ~:.~U~H~LlN~XF NOT USA)
6. FATHER
A. NAME Victor Ralph P~ri~i
B. COUNTRY OF BIRTH USA
14. EMPLOYMENT
A. USUAL OCCUPATIONOptical Assistant
B. TYPE OF INDUSTRY OR BUSINESS Retail
15. PLACE OF BIRTHWarsaw, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Timothy Hall Stephens
'B. COUNTRY OF BIRTJ-J S A
17. MOTHER
A. MAIDEN NAME Sandra Lee Dumbleton
B. COUNTRY OF BIRTJ-J S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
3B. DATE OF BIRTH
7. MOTHER
A. MAIDEN NAME niana Lynn Burke
B. COUNTRY OF BIRTH LJ S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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
II:
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1ST 0 0 1ST 0
~D 0 0 ~D 0
3RD 0 0 3RD 0
4TH 0 0 4TH 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impedim
as to my right to enter into the ~arnage ~tate.~ . _ .
21. SIGNATURE OF GROOM~ 1~ 22. SIGNATURE OF BRIDE~
USE CENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to periorm 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
ohn
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{ SEAL }
"-v-'
TIME MONTH YEAR MONTH YEAR
DATE
AM 07 15 2010 09 12 2010
02:34PM
28. PLACE WHERE MARRIAGE OCCURRED
~IGIOUS 10 CIVIL STATE NEW YORK B. COUNTY ~
A.
9 0 OTHER, SPECIFY
C.
SIGNATURE~
DOH-9B (09/20091