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COUNTY
~fTOWN
DISTRICT
NUMBI!fl
REGISTER
NUMBER
STATE OE~,NEWdYORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Carl Richard
Arnett
I
o/~~
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
Dutchess
Wappinger
1368
57
"
"A- ~~
Sft7/()iJ
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Catharine Jean
FIRST MIDDLE
1. A. FULL NAME
Cox
11. A. FULL NAME
FIRST
CURRENT SURNAME
MIDDLE
CURRENT SURNAME
Wiwcharuck
Cox
n/a
0-
N
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
c. CHECK ONE 0 CITY 0 TOWN ~ VilLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 25B No. Remsen Avenue ZIP 12590
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2 RESIDENCE A. New Yo r k
(STATE)
c. CHECK ONE iJ CITY 0 TOWN [J( VilLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 25B No. Remsen Avenue ZIP
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? Hi
3B. DATE OF BIRTH March / 12
MONTH DAY
097-64-1948
Dutchess
(COUNTY)
B.
12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13.B.DATEOFBIRTH Jan. /14 /1969
MONTH DAY YEAR
YES 0 NO
/1967
YEAR
13. A. AGE
31
3. A. AGE
33
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION
Unemployed
A. USUAL OCCUPATION Computer Technician
B. TYPE OF INDUSTRY OR BUSINESS Nine West
5. PLACE OF BIRTH Middletown. New York
(CITY. STATEiCOUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Revelstoke. British Columbia
(CITY, STATEiCOUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
B. NUMBER OF THIS MARRIAGE
Lawrence George Wiwcharuck
British Columbis, Canada
Carl David Cox
USA
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME Barbara Jean Russell
B. COUNTRY OF BIRTH Illinois , USA
1B. NUMBER OF THIS MARRIAGE Second
Nancy Davis
USA
Second
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
One
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
One
DEATH
DEATH
B. HOW 010 LAST MARRIAGE END? (31 [J( DIVORCE \3) 0 ANNULMENT (2) L... DEATH
C. DATE LAST MARRIAGE ENDED? Nov. / 23 /1999
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? X; YES ::::J NO
10. IF PREVIOUSLY DIVORCED OR ANNUlED. PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
11/23/99 Goshen, New York
B. HOW DID LAST MARRIAGE END? (3) ro DIVORCE :3) _ ANNULMENT '.21 = DEATH
C DATE LAST MARRIAGE ENDED? Augus t / 8 / 1999
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? X; YES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
8ATE OF DECREE PLACE ISSUED AGAINST WHOM
MONTH. DAY. YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
8/8/99 Port Hardy, BC ~
1ST
2ND
3RD
~ 1ST
o 2ND
::::J 3RD
o 4TH
ledge and belief that the Information I provided is true a
eclare that no legal impediment eXists
:J
21 SIGNATURE OF GROOM ~
~. SIGNATURE OF BRIDE ~
Deputy Town
May 5, 2000
w
en
z
w
o
::::;
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York tate 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.
~ If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
ERK 25. A. SOLEMNIZATION PERIOD BEGINS
ine Town Clerk
DATE 5/5/00
NY 12590
DATE
by New York Domestic
.-"-,
{ SEAL }
'-v-I
NAME (PRINT)
TIME MONTH YEAR MONTH YEAR
AM
2:15 PM 5 6 00 7 4 00
liP
28. PLACE WHERE MARRIAGE OCCURRED
,= CIVil NEW YORK Nil}u,.14
A. STATE B. COUNTY
SIGNATURE
M~~N~~~R1'24 ,
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
STATE
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 [J OTHER. SPECIFY
C. lOCATION OF CEREMONY
(CHECK ONE AND SPEClFYI
~ITY OF 0 TOWN OF = VilLAGE OF
SPECIFY tV I fY ~ 1+ PL::M.L.f'
STRE T
30. WITNESS TO CEREMONY
NAME (PRINT) C_...':..c.\ ~4"" o..! .~
SIGNATURE ~ ~ ·
DOH-88 (1111I8)
NAME (PRINT)
SlGNATURE~