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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
t~~2~7toeeFbyAffidavit MARRIAGE
FROM THE GROOM
I
"I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~: 1368
~5~1:~~R 118
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1. A. FULL NAME
.Ip.r~ Mir.h::lp.1 ~kp.rritt
M OLE CURRENT SURNAME
Wend~ Anne Jordan
MIDO CURRENT SURNAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 085-68-7641
2. RESIDENCE A. NY B. nllkhp.!=:!=:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN III VILLAGE
AND
SPECIFY W::lppingers Falls
D. STREET ADDRESS 72 Imperial Blvd: Apt 11 06 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 41 3B.DATEOFBIRTH 10 / 17 / 1q6R
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~kp.rritt
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 059-66-7784
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 1611 Route 376: Apt 11 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:1 NO
13. A. AGE 14 13B.DATE OF BIRTH * -AS .03/18 /1 976
. MONTH OA Y YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION HV AC'.
B. TYPE OF INDUSTRY OR BUSINESS Heating And Air
5. PLACE OF BIRTH Suffern, New York
(CITY. STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Property Manager
B. TYPE OF INDUSTRY OR BUSINESS Office Management
15. PLACE OF BIRTH Poughkeepsie. New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Matthew Salvatore Jordan
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Elizabeth Ann Humphries
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
6. FATHER
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A. NAME Mir.h::lp.1 Pp.tp.r ~kp.rritt
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joan Martha O'Neill
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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? 11/ 10 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? OOillfES 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
11/10/2003 Poughkeepsie. New York 0 d 1ST
o 0 2ND
o 0 3RD
o 0 4TH
Y knowledge and belief that the information I provided is tr e
(2) 0 DEATH
2003
YEAR
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
o
o
o
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best of
as to my right to enter into the marriage stat
21. SIGNATURE OF GROOM~
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USEC
23. SUBSCRIBED AND SWORN TO/AF MED 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
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
h C.
YEAR
~
DATE
by New York Domestic
~
{ } NAME (PRINT)
SEAL SIGNATURE"
'-v-I MAIL~B
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
MONTH
TIME
MONTH
AM
12:23>M
2010
10
31 2010
09
02
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY "~11.1rl j.e..
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF ~ VI~GE OF
SPECIFY }JiU) LV I V\I'J..GO V-
TITLE -P a ~,t 0 '(
DATE ID - Ifp- 10
NAME (PRINT)
SIGNATURE"
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Affidavit for Correction of Marriage Record
FOR OFFICIAL USE ONLY
State File #
District #
Date COl'Tl)leted:
STATE OF l\ tw \/O('/-
COUNTY OF D U..:td\ e., <; S
} SS:
Local Register #
2. Address:
J e-\('~
\LD\\
^~"cn(le-L.S.Kf-<("\+t andJD~('{j." Anne. 3Ordo..n
(Groom. Full Ntlmfl)~fI ~ Full MlI.idflfl Ntlmfl)
1. Names:
12590
(State) (Zip Code)
4. Date of Marriage: J 0 J J W / / 0
.
~.
D
5. List Items to Be Corrected:
Item Number
~ It DOES Appear (list exactly)
As It SHOULD Appear (list exactly)
6. Documentation Submitted:
~\r~h (\-U~I+\r:Ul-t<L
7. Explanation for Errors: (Explanation must specifically addtIss how and why each error occtm1d. Vague Of incomplete answers will not be inteqnted in YOIT ~I'C(. J
D('.x\~ -ht-ved l A ) ( /JrYj
Under penalty of perjury, I do hereby swear or affirm that the statements made herein are true and correct to the best of my knowledge and belief.
This affidavit with supporting documentation is being made for the pUlpose of having the record of marriage show the true facts and this affidavit will
become a permanent record. The marriage record. is filed with the State of New YOr1<.:Jt4'
.' MARK LIEBERMANN ~ ~/
Notary Public, State of New York
a Reg. No. 01 L16199007 Signatu usband
ualified in Dutchess County -
Commission Expires January 12, 2013 ~
Signature of Wife I
Subscribed and sworn to d 15 - d. 0 I ~
(~t.oom/fx1K5ld daym
NotaryPubhc ~___~
DOH.1827 (1109) Page 1 of 2
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Nell' Y or k S tate De [Jar t m ent 01 H eaith II
Albany, N. Y. 12237 ~
<1lertifitate of Iiiriq ~egistration ~
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This certifies that a certificate of birth has been filed under the name of:
WENDY ANNE JORDAN
Female
Born on:
March 18, 1976
At:
City of Poughkeepsie
, New York
Name 0/ father: Matthew Salvatore Jordan
Maiden name 0/ mother: Local Registration No.: 416
Elizabeth Ann Humphries
Date filed: March 23, 1976
Date issued: March 23, 1976
'-'v
egistrar of Vital Statistics
Address:Municipal Bldg., Poughkeepsie, N. Y.
This notice is void if it contains any erasures or corrections.