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COUNTY Dutchess
CITYffOWN Wappinger
~~~:~c:1368
~~~I:~~R 39
~ I A II: UI- NI:W YUHf\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Scott Andrew Mylie
MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Samantha Kelly Lamberg
MIDDLE CURRENT SURNAME
1 . A. FULL NAME
11. A. FUll NAME
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mylie
(OPTIONAL - SEE REVERSED63_56_9935
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE).L (COUNTY)
C. CHECK ONE IJ CITY U TOWN 0 VilLAGE
~~~CIFY Wappmger
o STREET ADDREssb3LJ Sherwood t- ores!
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)122 -68-84 71
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. CT B. Litchfield
(STATE) (COUNTY)
C CHECK ONE 0 CITY"6 TOWN 0 VILLAGE
~~~CIFY New Milford
D. STREET ADDRESS 6 Mountam Laurel Road ZIP 06776
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3 A AGE40 3B. DATE OF BIRTH 04 /02 /1969
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE34 3B. DATE OF BIRTH 02 )17
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTHSmithtown, Ny
(CITY, STATE / COUNTRY IF NOT USA)
lLb~U
ZIP
DYES 1] NO
)975
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION ManaQer
B. TYPE OF INDUSTRY OR BUSINESS Electronics
5. PLACE OF BIRTH Yonkers, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME RobertPaul Mylie
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Rose Marie Ryan
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
16. FATHER
A. NAME Arnold Lamberg
'B COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Marsha Sue Lind
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 2
w
en
z
w
(.)
:J
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DE.t-TH
o 0 1 1 0 U
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~ DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (58 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / 07 / 2006 c. DATE LAST MARRIAGE ENDED? 02 / 05 / 20
MONTH ~DAY YEAR MONT~ 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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE ~ONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST u2/05/2008 Poughkeepsie, Ny 0 ~
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and that to the bes of my knowledge and belief that the information I provided i I impediment exists
as to my right to enter into the m age tate.
21. SIGNATURE OF GROOM~ / !
, U
23. SUBSCRIBED AND SWORN ToAFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork 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) John C. Masterson
{I TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ .,''''' ,-----...... DATE 05/14/2009
'-.t-I MA~15GIOO~af~ ush Rd, Wappingers Falls, NY 12590 09:02AM 05 15 2009 07 13 2009
STREET CITYITOWN STATE ZIP PM
~~~R~~RT~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ~IVIL
DATE AND AT THE TIME AND ^<-
PLACE INDICATED. LI,..:<!. 9 0 OTHER, SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY-tj(.J.~1't s.s
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY \J.. Jr... pr', 'j i' I
SIGNATURE~
DOH-98 (03I2DD6)