046
. J coti'OY
aFiWrOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Scott
FIRST MIDDLE
Dutchess
Wappinger
1368
46
1. A. FULL NAME
Nichols
CURRENT SURNAME
..
~ N B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 092-60-3151
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE C CITY ~ TOWN 0 VILLAGE
AND Wappinger
SPECIFY
0 STREET ADDRESS 121 Robinson Lane ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 00 NO
3. A. AGE 37 3B. DATE OF BIRTH March /29 /1963
MONTH DAY YEAR
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This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New Yorl< State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used onl for the rpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME(PRINT)C]llV.ne H. ~wde~ Town Clerk TIME MONTH DAY YEAR
SEAL SIGNATURE~ F-th tIJ~-0"'.'V""6\A.Jt,~ DATE4/25/00
MAILING ADDRESS AM
'-.r-I PO Box 324 Wa in ers Falls NY 12 0 3: 00 PM 4 26 00
4. EMPLOYMENT
A. USUAL OCCUPATION Service Manager
B. TYPE OF INDUSTRY OR BUSINESS NeJ ame Pools
5. PLACE OF BIRTH poughkeepsie, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Robert Edward Nichols
USA
Gail June Case
USA
First
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
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
1ST 0
2ND 0
3RD 0
4TH 0
I, being duly sworn, depose and say. that to the best of my knowledge and
as to my right to enter into the n;t rriag state. -
21 SIGNATURE OF GROOM ~
23.
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r- STAll: ru.c "U"Ul;n
(THIS SPACE FOR STATE USE ONLY)
/ 19p:~loD
Lo SUPPLEMENTAL FILE ~
11. A. FULL NAME
FROM THE BRIDE
Christine Lynn
FIRST MIDDLE
Simon
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. (S~&Tt{ York B. (COUN~utchess
C. CHECK ONE 0 CITY Xi TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 121 Robinson Lane
Nichols
111-66-6111
ZIP 12590
:J YES Xl NO
/ 1973
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 26 13.B. DATE OF BIRTH Mav / 1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Financial Service Advisor
B. TYPE OF INDUSTRY OR BUSINESS Hudson Valley FCU
15. PLACE OF BIRTH Norfolk, Virginia
(CITY, STATE/COUNTRY IF NOT USA)
16, FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
John Martin Simon
USA
Vickie Lou Fessenden
USA
First
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
\2) C DEATH
B. HOW DID LAST MARRIAGE END? 1310 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSEIS) ALIVE? :J 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 1ST
o 2ND
:J 3RD
o 4TH
lief that the information I provided is t
o
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22. SIGNATURE OF BRIDE ~
2000
al impediment exists
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Deput Town Clerk
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
MONTH DAY YEAR
6 24 00
27. TYJE OF CEREMONY
o r;/ RELIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
TITlE~
(,//71'2..0<:JO
I '
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ltth'J J'l.1J
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~'TOWN OF 0 VILLAGE OF
SPECIFY G"a5t hSh Kill
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED
I AY Y
STATE
NAME (PRINT)
SIGNATURE ~