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COUNTY
l~I~(f:OWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappinger
1368
54
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
c.
MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
~)\3.IDO
L 0 SUPPLEMENTAL FILE
-.J
FROM THE BRIDE
H. Pike
MIDDLE CURRENT SURNAME
, . A. FULL NAME
.John
FIRST
F.aRtman
CURRENT SURNAME
11. A. FULL NAME
Gail
FIRST
0-
N
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Hprring
C. SURNAME AFTER MARRIAGE Eastman
(OPTIONAL. SEE REVERSE) 059-48-2984
O. SOCIAL SECURITY NUMBER
12. RESIDENCE A- New York B Dutchess
(STATE) (COUNTY)
C CHECK ONE o CITY Xl TOWN n VILLAGE
AND Wappinger
SPECIFY
o STREET ADDRESS 179 River Rd. No ZIP 12590
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
O. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE:
= CITY XI TOWN
Wappinger
179 River Rd. No
C. CHECK ONE
AND
SPECIFY
069-46-8360
B. Dutchess
(COUNTY)
VILLAGE
ZIP 12590
o YES []{ NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES~ NO
12 / 1954 13. A AGE 41 13.B. DATE OF BIRTH Dec. / 19 /1958
DAY YEAR MONTH DAY YEAR
o STREET ADDRESS
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILlAGE?
3 A. AGE 46 3B DATE OF BIRTH April /
MONTH
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Programmer
B. TYPE OF INDUSTRY OR BUSINESS IBM
15. PLACE OF BIRTH poughkeepsie, New York
(CITY. STATEiCOUNTRY IF NOT USA)
A. USUAL OCCUPATION Technician
B. TYPE OF INDUSTRY OR BUSINESS Micrus
5. PLACEOFBIRTH Brooklyn, New York
,CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
A. N~E Vincent J. Herring
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN ~E
Walter A. Eastman
USA
B. COUNTRY OF BIRTH
Florence Morano
USA
Third
Marylou Cesare
USA
Second
18. NUMBEFl. OF THIS MARRIAGE
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
OIVORCE CIVIL ANNULMENT
One
DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
Two
DEATH
B. "OW DID LAST MARRIAGE END? (3)~ DIVORCE 31 U ANNULMENT ,2) ~ DEA T~
C. ::lATE LAST MARRIAGE ENDED? Mav /01 / 2000
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
MONTH. DAY. YEAR) ,CITY. STATE:COUNTRY. 'F NOT USAI SELF SPOUSE
2/16/88 Hudson, New York ~
5/1/00 Dutchess Co., NY ~
B. HOW DID LAST MARRIAGE END? i31~ DIVORCE :3) 0 ANNULMENT ,21 L DEATH
C. DATE LAST MARRIAGE ENDED? Ma'L /23 /1995
\4Ot\lTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 1,rYES :J NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEARI 'CITY. STATE-COUNTRY. IF NOT USA) SELF SPOUSE
5/23/95 Middlesex Co., NJ ,. ~
1ST
2ND
3RD
L.J
4TH
I. being duly sworn. depose and say, that to the bes
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~
c
Town Clerk
DATE
May 5, 2000
w
en
z
w
CJ
::::i
23. SUBSCRIBED AND SWORN TO BEFO E
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in ew York State of the bride and groom named above by any person authorized
Relations Law ~11 to pertorm 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 rpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT)~aine ~nowden2 Town Clerk
{ SEAL SIGNATURE~ll~~A.~~'J. DATE 5/5/00 TIME MONTH DAY YEAR
MAILING ADDRESS AM
'-v-I PO Box 324 Wa in ers Falls NY 12590 12:15PM 5 6 00
~a I A
~~R~~~Ri~~~ IO~~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE 1M DAY Y 0 0 RELIGIOUS 1-,( CIVIL
DATE AND AT THE TIME AND J" ~ <fIlttIr 0
PLACE INDICATED IlK PM / 0 () 9 0 OTHER. SPECIFY
Nt S. !:'RittJCESG
VILLAGE OF
by New York Domestic
25. B. SOLEMNiZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
7
4
00
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY UiJ'f<;.tf6r;:
29. OFFICIANT
NAME (PRINT)
TITLE &J1/~ ~1ic:ti:JI:z? I
DATE ;rove /()/ :l()()O
1t' A&ee S ~s: II. ;:;5'10
STATE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
SPECIFY
STREET CITYfTOWN
30. WITNESS TO CEREMONY u /
"",,,"~n _ _~YGAl 1(/' j(#/ ",;;/J
SlGNATURE~ ~ 1,t.. ~
DOH-98 (1198)
NAME (PRINT)
SIGNATURE ..