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C JUNTY nlltr.hF'~~
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~~~~;~R 114
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Dlilvi~it;,hri5itopher ~~~NAME
I""
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
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1. A. FULL NAME
11. A. FULL NAME FIRST DE'br;:\fo~l~F'n M::lr.~IJ~i?JrLRNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Myers
c. s~S~*~tt.~~~~t~~b~~s~llrray
D SOCIAL SECURITY NUMBER 119-60-3108
12. RESIDENCE A. NY B. nlltr.hF'~~
(STATE) (COUNTY)
C. CHECK ONE D CITY Q'I TOWN D VILLAGE
~~~CIFY Fi~hkill
D STREET ADDRESS 56 Florence Ave
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1.:1.:1-7 o-q 114
2. RESIDENCE A. NXTATE) B. ~~eSiSi
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS ~R FlorAnr.F' AVA ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES 'It! NO
MO~ / Dlf / y1,g66
3B. DATE OF BIRTH
O~
MONTH
ZIP 12524
DYES <ri NO
/f'Q71
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
A1
DAY
13. A. AGE 38
3. A. AGE 43
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Trl.lck Dri"er
B. TYPE OF INDUSTRY OR BUSINESS R::lilrn::lrl C':ontr::ldor
5. PLACE OF BIRTH E nall"woorl N.I
(CITY:-$TATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Kenneth R M'lrray Ir
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME .I::lnpt Rllth .Iorrl::ln
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION St::lY At Homp. Mom
B. TYPE OF INDUSTRY OR BUSINESS Mom
15. PLACE OF BIRTH White olains, NY
(CITY, STATer COUNTRY IF NOT USA)
16. FATHER
A. NAME Arthllr ~poq)A MYAr~
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Colette Frances Morrow
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DEATH DIVORCE CIVIL ANNULMENT DEATH
o n 1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) D ANNULMENT (2) D DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 05/ n~ / ?nnR c. DATE LAST MARRIAGE ENDED? 10 / 05 / 2007
MONTH DAY YEAR MONTH DAY - YEAR
0, ARE ANY FORMER SPOUSE(S) ALIVE? eWES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES D NO
~
1D. 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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST n~tn~/?OOR \NoorlhrirlgA, N.I [y' D 1ST 10/05/2007 Poughkeepsie, NY D l!l'
2ND D D 2ND D D
3RD D D 3RD D D
4TH D D 4TH D D
I duly swei\r/affirm, depose and say, t to the best of my knowledge and belief that the information I provided is truemn ha I deClar;J2. th t nO~gal' pedimezt e 'sts
as to my nght to enter Into the marr ge tate, /
21. SIGNATURE OF GROOM~ c 22. SIGNATURE OF BRIDE~ A ~ ~ ifYJc...A.-z
SE USE CURRENT 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 by New York Domestic
Relations Law ~11 to pertorm marriage ceremonies within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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) John C
9, ~R~~~~{RM&R~~'t<tT8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1
DATE
09/25/2009
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{ SEAL }
'-v-I
YEAR
MONTH
YEAR
TIME
MONTH
AM
02:33PM
2009
11
24 2009
09
26
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
1;ff CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYflp/Me:;:iS
C, LOCATION OF CEREMONY
(CHECK ONE t~D SPECIFY)
D CITY OF J'f TOWN OF D VILLAGE OF
SPECIFY ~ffr5 r .f'l~I/J
~ '--.
TITLE ~?t-- V~/(!'f?-,;
DATE /~l
M / ~7..3
ZIP
SIGNATURE~
DOH-98 (03I2DD6)
NAME (PRINT)
SIGNATURE~