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086 "- N + !z W en W '" c B J: en z o ~ < 0: >- en a W 0: W Cl < a: 0: < ::; "- o ~ () ii: ~ W () W 0: W i en en W 0: C C < ~ o W "- en 0:' 1Il ::l! ::> z o z < tii w 0: Iii + ~M w ~~~ ll!~~ ~ tii~~ (.) ::l()W ::l!Cl5 u: !zi!:en - ~~~ t: itoen W 0>->- wljj~ (.) Sffi'" zgi!: COUNTY Dutchess CITYfTOWN WappinQer ~~~:~c: 1368 . ~G~I~~~R 86 STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM Eric J Baller MIDDLE CURRENT SURNAME I STATE FILE NUMBER (THIS SPACE FOR STA TE USE ONL Y) I L 0 SUPPLEMENTAL FILE FROM THE BRIDE Cristi L Cook MIDDLE CURRENT SURNAME ~ 1. A. FULL NAME 11. A. FULL NAME FIRST FIRST B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE D. s~:~~~~I~E~U~~RSE) 058-54-1785 2. RESIDENCE A. NY B Dutchess (STATE) (COUNTY) C. CHECK ONE 0 CITY fj TOWN 0 VILLAGE ~~~CIFY Poughkeepsie D. STREET ADDRESS 11 Malmros Terrace ZIP 12601 E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tj NO 3. A AGE 35 3B. DATE OF BIRTH 10 / 07 / 1973 MONTH DAY YEAR B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT C. SURNAME AFTER MARRIAGE Baller (OPTIONAL. SEE REVERSE) 1 05-68-4405 D. SOCIAL SECURITY NUMBER 12. RESIDENCE A. NY B Dutchess (STATE) (COUNTY) C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE ~~~CIFY PouQhkeepsie D. STREET ADDRESS 11 Malmros Terrace ZIP 12601 o YES'6 NO )1'977 YEAR E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 13. A. AGE 32 3B. DATE OF BIRTH 02 /07 MONTH DAY 14. EMPLOYMENT A. USUAL OCCUPATION ManaQer B. TYPE OF INDUSTRY OR BUSINESS Staples 15. PLACE OF BIRTH Bay Shore, NY (CITY. STATE I COUNTRY IF NOT USA) 16. FATHER A. NAME John Provan Cook 'B. COUNTRY~F BIRTH USA 4. EMPLOYMENT A. USUAL OCCUPATION Field Rep. B. TYPE OF INDUSTRy.oR BUSINESS Central Hudson 5. PLACEOFBIRTH PouQhkeepsie, NY (CITY, STATE I COUNTRY IF NOT USA) 6. FATHER A. NAME Janos Gyorgy Baller B. COUNTRY OF BIRTH HunQarv 7. MOTHER A. MAIDEN NAME Elaine Gay Jaycox B. COUNTRY OF BIRTH USA 8. NUMBER OF THIS MARRIAGE 1 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 17. MOTHER A. MAIDEN NAME Carol Jean Wilson B. COUNTRY OF BIRTH USA 18. NUMBER OF THIS MARRIAGE 1 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DEATH o DEATH o B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (2) 0 DEATH (3) 0 ANNULMENT (2) 0 DEATH / / ..- YEAR MONTH DAY YEAR D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO 10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM (MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? . MONTH DAY D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO ~ 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM (MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (3) 0 ANNULMENT / / 1ST 2ND 3RD 4TH I duly swear/affirm, depose and say, that to the as to my right to enter into the marrrage state. 21. SIGNATURE OF GROOM. o 0 1ST o 0 2ND o 0 3RD o 0 4TH owledge and belief that the information I provided is t o 0 o 0 o 0 o 0 that no legal impediment exists 08/20/2009 W UJ Z W (.) :i 23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFO 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 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) Jo C. Masterson { C TIME MONTH YEAR MONTH SEAL SIGNATURE ~ DATE 08/20/200 '-v-I MAI~ ~?~a\s sh Rd, Wappingers Falls, NY 12590 08:43AM 08 21 2009 10 19 2009 STREET CITY/TOWN STATE ZIP PM ~~~R~~Ri~~J IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY SONS NAMED ABOVE ON THE TI MO.' DAY YEAR 0 ch RELIGIOUS DATE AND AT THE TI E AND 0 t. F PLACE INDICATED. I 9 0 OTHER, SPECIFY DATE YEAR 10 CIVIL 28. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNTY ;J frSSIlv\. ......... NAME (PRINT) SIGNATURE~