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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c;1368 .
~~~~J~R 160
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Francis Montross
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
-,
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jillian Erica Smith
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FUll NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Montross
(OPTIONAL - SEE REVERSE1084_88_2075
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA.NY B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VilLAGE
~~~CIFY Fishkill
D. STREET ADDREss31 Fairfax Rd
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 095-76-8534
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY \(] TOWN 0 VILLAGE
~~~CIFY Fishkill
o STREET ADDRESS 31 Fairfax Rd ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tJ NO
05 /29 /1983
MONTH DAY YEAR
ZIP 12524
DYES '6 NO
,A'983
YEAR
3. A. AGE ?7
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPOAA TED VILLAGE?
13. A. AGE 27 13B.DATE OF BIRTH 01 /f 8
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH poughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Automotive Tech
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH poughkeepsie. New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Richard Paul Montross
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Rae Marie Galioto
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
16. FATHER
A. NAME John E. Smith
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Kathleen A. Blaikie
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
DEATH
o
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
a:
w
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1~ 0 0 1~ 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH ., 0 0 4TH 0 0
I duly sweiir/affirm, depose and say, th t tq' est of my knowledQ.e and belief that the information I provided is true and that I declare tha no legal impediment exists
as to my nght to enter Into the mamag s. e. /~~ U - ~
21. SIGNATURE OF GROOM" 22. SIGNATURE OF BRIDE" L' '-- "'"'-
USE cu NAME USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME '" 11/19/2010
SIGNATURE OF TOWN OR CITY CLERK ~ / DATE
This license authorizes the marriage in New Y State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to periorm marriage ceremonies wit in 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
} NAME (PRINT) Johp C. Mas erson
{SEAL SIGNATURE~ . ". II -.i'._.__ DATE 11/19/2010 TIME MONTH YEAR MONTH
'-v-' MAI~ ~r8ais ush Rd, Wappingers Falls, NY 12590 03:35;~ 11 20 2010 01 18 2011
STREET CITYITOWN STATE ZIP
~~~R~~RT~~J IO~O~~~N~:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o'Dfl. RELIGIOUS
DATE AND AT THE TIME AND . '1 r
PLACE INDICATED. " ':) I () 9 0 OTHER, SPECIFY
~
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 0 nma.&.
C. LOCATION OF CEREMONY J
(CHECK ONE AND SPECIFY)
o CITY OF 18 TOWN OF
29. OFFICIANT
NAME (PRINT)
ZIP V\
31. WITNESS TO CEREMONY
NAME (PRINT) J\ iL"o..rt-\. r Mct1'f'1O"i>S ]I:.
SIGNATURE~ ~ Vv,--
