048
STATE OF NEW YORK I STATE FILE NUMBER I
Dutchess (THIS SPACE FOR STA TE USE ONL Y)
COUNTY DEPARTMENT OF HEALTH
\.emtTO'NN Wappinger /5/,doZl
DISTRICT 1368 AFFIDA VIT, LICENSE and
NUMBER
REGISTER 48 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Anthony C. Blake 11. A. FULL NAME Rachel Conley
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
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B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STAU') (COUNTY)
C. CHECK ONE 19 CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
0, STREET ADDRESS 10N Lockey Woods Rd.
12508
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STA"iji) (COUNTY)
C. CHECK ONE 0- CITY 0 TOWN 0 VilLAGE
~~~CIFY Beacon
o STREET ADDRESS 10N Lockey Woods Rd. ZIP
Blake
115-76-3161
067-60-1675
12508
ZIP
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 23 3B.DATEOFBIRTH May / 10 /1976
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Xi YES 0 NO
13.B.DATEOFBIRTH Sept. / 14 /1974
MONTH DAY YEAR
13, A. AGE
25
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Mail Handler
B. TYPE OF INDUSTRY OR BUSINESS U.S. Postal
5. PLACEOFBIRTH Bronx, New York
(CITY, STATE/COUNTRY IF NOT USA)
Clerk
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESS U. S. Po s tal
15. PLACE OF BIRTH Beacon, New York
(CITY, STATE/COUNTRY IF NOT USA)
Service
Service
16. FATHER
A. NAME
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Edward Conley
USA
Charles Blake
USA
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
Valerie Hoert
Frances Yanarella
B. COUNTRY OF BIRTH
1B. NUMBER OF THIS MARRIAGE
USA
First
USA
First
B. NUMBER OF THIS MARRIAGE
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? 13) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
121 0 DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
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
YEAR
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is true
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21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE
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23. SUBSCRIBED AND SWORN TO BEFORE
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.
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)~ne H. Snowde~ Town Clerk
{SEAL SIGNATURE ~ (--0(1.1 It l ~ ~ A.-I"'f-...rJp{- DATE 5/2/00 TIME MONTH DAY YEAR
~.ll-IN~ ADDR~S.s . AM
~ ~U tloX JL4, Wapplngers Falls, NY 12590 2:35 PM 5 3 00
STREET CITY/TOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- ~
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR RELIGIOUS 1 ~Vll .
DATE AND AT THE TIME AND ~
PLACE INDICA ~
01
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
7
28. PLACE WHERE MARRIAGE OCCURRED
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY,
o CITY OF 0 TOWN OF ILLAGE~
SPECIFY ~AiIll6
NAME (PRINT)
SIGNATURE ~
DOH.9B (1/98)