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COUNTY Dutchess
CITYITOWN Wappinger
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~5~I~J~R 158
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jeffre~ Michael Gulick
MID LE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Vanessa Claire Santos Miller
FIRST MIDDLE CURRENT SURNAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 01 74-4316
D. SOCIAL SECURllY NUMBER -
2. RESIDENCE A. NY B. Dutchess
(STAlE) (COUN1Y)
C. CHECK ONE "D CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
D. STREET ADDRESS 510 Main St: Apt 9 ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 27 3B. DATE OF BIRTH 07 / 17 / 1983
MONTH DAY YEAR
MONTH
08
13. A. AGE 26
13B.DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Police Officer
B. TYPE OF INDUSTRY OR BUSINESS Law Enforcement
5. PLACE OF BIRTH PouQhkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Administrative Assistant
B. TYPE OF INDUSTRY OR B.l.L~INFSS Retail
15. PLACE OF BIRTH White t-'Ialns, New York
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A. NAME Bruce David Miller
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mercedes Maria Costa Santos
B. COUNTRY OF BIRTHPortugal
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL ANBULMENT
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6. FATHER
A. NAME Walter H. Gulick Jr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Deborah L. Ryder
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEeTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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
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
tJ)
z
W
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1ST 0 1ST
",' 2ND 0 2ND
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DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
} NAME (PRINT)
{SEAL SIGNATURE ~
MAI~ AA~
'-v-'
TIME
MONTH
YEAR MONTH DAY YEAR
DATE 11/17/201
s, NY 12590
AM
02:52pM
11 18 2010 01 16 2011
ZIP
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED A80VE ON THE
DATE AND AT THE TIME AND
PLACE INDIC
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~\olj'c:.~
C. LOCATION OF CEREMONY
(CHECK ONE AND yeCIFY)
o CITY OF [Q"'tOWN OF 0 VILLAGE OF
SPECIFY IN r6rf'P I ~
1~
SIGNATURE~
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ~L...r' l1- ~ ar
SIGNATURE~ ~ ~ ::J1J!
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