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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~
