051
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COUNTY
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NUMBER
REGISTER
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1 A FULL NAME
51 A 1E OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David D.
FIRST MIDDLE
~~M~H~eAME
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
Dutchess
Wappinger,
1368
51
131
L J SUPPLEMENTAL FlfEO~,~,,~;16 rl~ ~
FROM THE BRIDE
L
MIDDLE
'Wpl!'lh
CURRENT SURNAME
TnlH
FIRST
11. A. FULL NAME
8 BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER
2 RESIDENCEA. New York
(STATE)
C CHECK ONE ~ CITY 0 TOWN 0
~~~CIFY Beacon
o STREETADDRESS 1 Vine Street
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE We Ish
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 122-60-0101
12 RESIDENCEA. New York B DIITl'np!'l!'l
(STATE) 15SQNTYl
ltl CITY 0 TOWN 0 VILLAGE
081-64-6995
B. D(~~ess
VILLAGE
C. CHECK ONE
AND
SPECIFY Rp.<ll'nn
D. STREET ADDRESS 1 Vi n P ~ 1" r P p 1" ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? :l[]
13. A. AGE ?f. 13.B. DATE OF BIRTH M~~J:l / iAY
ZIP 1 ?'iOR
~YESONO
17/1Q70
DAY YEAR
1?508
YES 0 NO
/i ~EI:I
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A AGE 29 3B. DATE OF BIRTH Dpl'. /
MONTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION
Homemaker
A. USUAL OCCUPATION Inventory Control
B. TYPE OF INDUSTRY OR BUSINESS Dobson Communications
5. PLACEOFBIRTH Poughkeepsie New York
(CITY, STATE/COUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OR BUSINESS _
15. PLACE OF BIRTH Yonkers New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
16. FATHER
A. NAME Richard D. Welsh
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Barbara Galli
B COUNTRY OF BIRTH USA
A. NAME Jose E. Segarra
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME T ,ynn r.~ <=lP
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE
First
lB. NUMBER OF THIS MARRIAGE
Fin::t
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
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
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. 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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ge and belief that the in ormation I provided is tru
o 0
o 0
o 0
D 0
no legal impediment exists
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
Deputy Town
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 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 only for the urpose of a second or subsequent ceremony.
24. TOWN OR LERK 25. A. SOLEMNIZATION PERIOD BEGINS
ine H. Snowden, Town Clerk
25. 8. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
~
{ SEAL }
'--t-I
NAME (PRINT)
TIME MONTH DAY YEAR MONTH DAY YEAR
DATE 5/3/00
NY 12590 AM 05 04 00 07 02
STATE ZIP 12 :30PM
27. TYPE OF CEREMONY 2B. PLACE WHERE MARRIAGE OCCURRED
00 CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDtC
NAME (PRINT)
SIGNATURE ~