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COUNTYDutchess
CITYfTOWN Wappinger
~~~:~c~1368
~5~I~J~R145
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ian Bruckner Brent
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
Maureen C Alarid
-.J
1. A, FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
..
f;j
B. BIRTH NAME (MAIDEN NAME)B' DIFFERENT
C. SURNAME AFTER MARRIAGE rent
(OPTIONAL - SEE REVERSE'! 17-60-5371
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ~Y putchess
(STATE) ~ (COUNTY)
C. CHECK 00". 0 CITY 0 TOWN 0 VILLAGE
~~CIFYvvapplnger
10 t:S vvmtegate Dr
D. STREET ADDRESS
B. BIRTH NAME. IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSElt 03 72 4103
D. SOCIAL SECURITY NUMBER I - -
2. RESIDENCE A. NY B. Putnam
(STATE) (COUNTY)
C. CHECK ONE 0 crr'l""'b TOWN 0 VILLAGE
~CIFY Carmel
D. STREET ADDRESS 22 Rosemarie Lane ZIP 10541
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~'b NO
07 /24 /1987
MONTH DAY YEAR
3. A. AGE?2
3B. DATE OF BIRTH
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORAO~ VILLAGE?':VI 0 Yfj,S"p,-!o
13. A. AG~2 3B. DATE OF BIRTH ~ E
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATlo~etail
Ketall
B. TYPE OF INDUr.TflY OR BUSllte~S
15. PLACE OF BIRTt-t'_onnson ~Ity, New YOrK
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMERobert Stephen Horton
'B. COUNTRY OF BIRT.}! S A
17. MOTHER J G "ff"th
A. MAIDEN NAME Margaret ane n I s
B. COUNTRY OF B;JJ S A
'L
18. NUMBER OF THIS MARRIAGE
4. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS SUNY New Paltz
5. PLACE OF BIRTH Yonkers, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Eric Stowell Brent
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Bonni Jean Bruckner
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARI:IIAGE 1
a:,'
w
m
::E
f
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t;
w
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19. ~~~~~~?RMtFR~K'E<tlr8us MARRIAGES WHICH ENDED BY
D1'ORCE CIVIL A~ULMENT
~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORf2 (3) ~~NULMENT 2d8~ DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTijo' DAY' ',- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE{S) ALIVE? 0 YES 0 NO
to
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE (MONTH. DAY, YEAR) (CITY~UNTY. SlA1EICOU~Y, IfNOl' USA) SELF SPO.:fE
1ST 0 0 1ST 12/16/2009 New york, New YOrK 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swe!lr/affirm. aep'ose and say, that to the best of my knowledge and belief that the information I provided is t 0 legal impediment exists
as to my nght to enter Into the mama estate.
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DtfTH
USE RR NT NAME
23, SUBSCRIBED AND SWORN TO/AFFIRMED 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 purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Joh C. Masterson
TIME MONTH DAY YEAR
SEAL SIGNATURE ~ DATE
MAILING ADpRElls 10:50AM 12 30 2009
'-v-' 20 Mldaleb PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
MONTH
YEAR
02
27 2010
l~CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY'j)Jm~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF )(.vILLAGE OF
SPECIFY i/hPod'f3;d!A' I?kd
ZIP
"'WITN''''~. ,', ~~j_ "
NAME (PRINT) . ---~JZ:;; IS
SIGNATURE"-