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COUNTY
~TOWN
" D'STqIC~l'-
NUMBER
REGISTER
NUMBER
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Joseph A.
FIRST MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
Dutchess
Wappinger
1368
29
~5,,"Oi)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lori Ann Vaillancourt
FIRST MIDDLE CURRENT SURNAME
-.J
Duke
11. A. FULL NAME
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Lion
c. SURNAME AFTER MARRIAGE Du ke
(OPTiONAL. SEE REVERSE) 126-44-3679
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
o CITY ~ TOWN 0 VILLAGE
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER
New York
(STATE)
C. CHECK ONE 0 CITY IX TOWN 0 VILLAGE
~~~CIFY East Fishkill
D STREET ADDRESS 240 White Pond Road
E. IS RESIDENCE WITHIN LIMITS OF cIJdfRNmYO!frJo~ILLAGE?
3 A. AGE 34 3B. DATE OF BIRTH Aug. /
MONTH
2 RESIDENCE A
052-54-4730
Dutchess
(COUNTY)
C. CHECK ONE
AND
SPECIFY
12590
B.
Wappinger
25C Scarborough Lane
ZIP 12582
o YES Xl NO
24 /1965
DAY YEAR
ZIP
D STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Xi NO
13.B. DATE OF BIRTH Aug. /26 ~ 96 7
MONTH DAY YEAR
13. A. AGE
32
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Social Worker
B. TYPE OF INDUSTRY OR BUSINESS Cortlandt Nursing
15. PLACE OF BIRTH Long Island City, New York
(CITY, STATE/COUNTRY IF NOT USA)
Care
Center
A. USUAL OCCUPATiON Landscaping
B. TYPE OF INDUSTRY OR BUSINESS Self employed
5. PLACE OF BIRTH Redondo Beach, California
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Ann Kull
USA
Second
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Wallace Duke
USA
Benard Lion
Germany
Lucille Bateman
USA
First
18. NUMBER OF THIS MARRIAGE
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
One
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3)Xi DIVORCE (3) 0 ANNULMENT (21 0 DEATH
C. DATE LAST MARRIAGE ENDED? July / 8 /1993
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? Xl 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
7/8/93 Carmel, New York
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(Sj 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
o
o
o
1ST
2ND
3RD
o
o
o
o
o
o
1ST
2ND
3RD
4, 2000
w
en
z
w
()
::i
This license authorizes the marriage in New York 5t e 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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Elaine Town Clerk
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
,-'-..
{ SEAL }
'-.t-I
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
DATE 4/4/00
NY 12590
SIGNATURE ~
MAILING ADDRES
PO Box 324,
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
1: 00 PM
4
5
00
6
3
00
Wappingers Falls,
CITY ITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
ZIP
STATE
27. TYPE OF CEREMONY
o'l<l' RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Ou+che~
c. LOCATION OF. CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF j!.! VILLAGE OF
<<J
4:00
29. OFFICIANT Hn., ~c..("\d(c.... \2> M an ~-...
NAME (PRINT) !....\"-~. . - \..L,
SIGNATURE ~ '-IZa". ~a.. '& ?l1Cl.fL;t %
MAILING ADDRES~ ~
q Me-sier A01J. 1o...a."W'\ I I.JI'".L(>O\()Ctt2(')
STREET CITYfTOWfol \" J
~.:;~:::~ ~d ~ ~~e
SIGNATURE~~iJ t-~
DOH-98 (1/98)
TITLE
M \1\ b-\er
r:_(,~CO
SPECIFY l.J~(\CorS
u
Fo.ll j
DATE
~ 5'10
ta \ \ S J rJ I.( .
STATE ZIP
31. WITNESS TO CEflEM.ONY
NAME (PRINT) /....
SIGNATURE ~
/~-~.- """)