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COl' oJTY
_TOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF,:NEW,NORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Wayne George VanEtten
FIRST MIDDLE CURRENT SURNAME
r-
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
Dutchess
Wappinger
1368
55
/ ~ \'j.~\.D
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tracey Ellen
FIRST MIDDUE
-.J
Duggan
CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
Dugan
Duggan
123-58-1825
B. Dutchess
(COUNTY)
o VILLAGE
0-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTlONAl . SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE.4. New York
(STATE)
C. CHECK ONE 0 CITY Ki TOWN
~~IFY Fishkill
D. STREETAODRESS 4 Crossway Road
.Beacon
E. IS RESiDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Xi NO
13. A. AGE 39 13.B.OATEOFBIRTH Jan. / 14 /1961
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl' SEE REVERSE)
O. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE)
o CITY ~ TOWN
Fishkill
O. STREET ADDRESS 4 Crossway Road
Beacon
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 36 3B. DATE OF BIRTH Dec. /
MONTH
C: CHECK ONE
AND
SPECIFY
085-48-2405
B. Dutchess
(COUNTY)
o VILLAGE
ZIP 12508
o YES~ NO
22 /1963
YEAR
ZIP 12508
DAY
14. EMPLOYMENT
A. USUAL OCCUPATION
Disabled
4. EMPLOYMENT
A. USUAL OCCUPATION Design/Drafter
B. TYPE OF INDUSTRY OR BUSINESS Huck International
5. PLACE OF BIRTH Kingston, New York
(CITY. STATE/COUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Peekskill, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
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6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
18. NUMBER OF THIS MARRIAGE
Harold E. VanEtten, Sr.
USA
A. NAME William G. Duggan
B. COUNTRY OF BIRTH USA
17. MOTHER
Heiser
A. MAIDEN NAME
Elsie Virginia Gordineer
Ann Marie
USA
Second
B. COUNTRY OF BIRTH
USA
Third
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
Two
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
B. HOW DID LAST MARRIAGE END? 13) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? June / 17. / 1998
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 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
1ST 6/17/98 Kingston, New York
2ND
3RD
4TH
I, being duly sworn, depose and say,
as to my right to enter into the m 'ag
DEATH
DEATH
B. HOW OlD LAST MARRIAGE END? (3) XI DIVORCE (3) C ANNULMENT ,2) C OEATH
C. DATE ..AST MARRIAGE ENDED? Fe b. / 26 / 1999
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? XJ YES C NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE Of' DECREE PLACE ISSUED AGAINST WHOM
(MONTH. 'JAY. YEAR) (CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
6/1/98 Dutchess Co., NY
2/26/99 Dutchess Co., NY
L.
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x::
21. SIGNATURE OF GROOM.
1ST
2ND
3RD
C
Lj 0
Town
DATE May 5, 2000
by New York Domestic
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23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York Stat 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 onl for the pu S9 of a second or subsequent ceremony.
RK 25. A. SOLEMNIZATION PERIOD BEGINS
ine Town Clerk
DATE 5/5/00
NY 12590
7 4 00
24. TOWN 0
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
~
{ SEAL}
'-..t-I
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH DAY YEAR
AM
PM
5
6
00
1:15
28. PLACE WHERE MARRIAGE OCCURRED
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT'THE TIME AND
PLACE INDICATED.
27. TYPE OF CEREMONY
o Jl!l,. RELIGIOUS 1:: CIVIL
9 0 OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY ".iAJ it,t)ess
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF )li{ VILLAGE .OF _
SPECIFY l~~~-e~~l\s
NAME (PRINT)
SIGNATURE.
DOH-II (11ll8)
NAME (PRINT)
SIGNATURE ..