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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368 .
~~~~;~R 130
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~i<tt!~E(1 . lemA!=: ~Pj.J~URNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Samantha Ann Cannon
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 050-74-1828
2. RESIDENCE A. NY B. nllt~hA!=:!=:
(SrATE) (COUNTY)
C. CHECK ONE 0 CITY !ill' TOWN 0 VILLAGE
AND W .
SPECIFY applngAr
D. STREET ADDRESS 11 D Carnaby St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES I!f NO
3. A. AGE 28 3B. DATE OF BIRTH MONQJ3 / D!8 / yl.~82
4. EMPLOYMENT
A. USUAL OCCUPATION ~e~llrity
B. TYPE OF INDUSTRY OR BUSINESS Indian Point
5. PLACE OF BIRTH Mount Ki!;co, New York
(CITY, STATE / COUNTRY IF NOT USA)
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE r.a hill
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 068-70-4248
12. RESIDENCE A. NY B. DutchA!;S
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 11 D Carnaby St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:!1 NO
/1 0 /19R!i
DAY YEAR
13. A. AGE ?5
13B.DATE OF BIRTH
05
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Accounting
B. TYPE OF INDUSTRY OR BUSINESS Arnott Moving
15. PLACE OF BIRTH Cold Sorina. New York
(CITY, STATE 1c0UNi'Ry IF NOT USA)
16. FATHER
A. NAME RohArt Edward Cannon
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Bernadette Bridget McCann
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
6. FATHER
A. NAME Thnma!=: J= r.ahill
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marga rAt R Gowan
B. COUNTRY OF BIRTH LJ S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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
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
w
en
z
w
o
::::i
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swe~r/affirm, dep.ose and say, that to the best of my knowllldge and belief that the information I provided is tru~d that I declare that no legal impediment exists
as to my nght to enter Into the marrrage !\late. /7
21 SIGNATUREOFGROOM~ 2.SIGNATUREOFBRIDE~ <:::: 'h1'~~ /./. 4ArA
USE CUR . USE CURRENT 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 ~1110 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
o n C.
DATE
09/22/2010
r-"-.
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-v-' 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.
TIME
MONTH
YEAR
MONTH
YEAR
2010
09
23
11
21 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Ud .4w6Jt
C. LOCATION OF CEREMONY
(CHECK ONE AN~PECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY ~HJ lCAlt/i_
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)