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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian Scott Lankester
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368
~~~I:~~R 29
1. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)122 -70-6014
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY WapPin~er
D. STREET ADDRESS 6C carborough Lane
3. A. AGE 38
12590
ZIP
YES fJ NO
/1971
YEAR
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lori Jessica Marlin
~
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? 0
01 / 19
DAY
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Union Sheet Metal Worker
B. TYPE OF INDUSTRY OR BUSINESS Heating And Air
5. PLACE OF BIRTH Yonkers, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Leslie Herbert Lankester
B. COUNTRY OF BIRTH USA
7, MOTHER
A. MAIDEN NAME Patricia Anne Mclean
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
11. A. FULL NAME
MIDDLE
CURRENT SU RNAME
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
FI,RST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Lankester
(OPTIONAL. SEE REVERSEl122 -68-024 7
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY BDutchess
(ST ATE) oJ.. (COUNTY)
C. CHECK Otlii . 0 CITY IJ TOWN 0 VILLAGE
~~~CIFY wappinger
D. STREET ADDRESS6C Scarborough Lane
ZIP 12b!:lU
DYES ''6 NO
)'979
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE29 3B.DATEOFBIRTH 12 ~O
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTH Mt. Vernon, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Clifford Marlin
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A, MAIDEN NAME Nancy Everin
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DE8TH
(3) 0 ANNULMENT
/ /
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) (CrTY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
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
o
o
o
1ST 0 0
~D 0 0
3RD 0 0
~ 0 0
t the information I provided is tru~n~ that I deClar~ that .no legal imp~diment exists
.SIGN UREOFBRIDE. ~ /l/JlJ.J.fLA ~
~SE CURRENT NAME
. DATE 05/01/2009
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US CURRENT
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) Jo C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 05/01/2009
I....- -..J MAIJ,.lI)l.,Gf.rJIPjEReS 09:49AM 05
-v- LU IVI ual sh Rd, Wappingers Falls, NY 12590 PM
STREET CITYfTOWN STATE ZIP
~~~R~~RTr~; lo~O~~~N~Zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ~ CIVIL
DATE AND AT THE TIME AND AM- r'\
PLACE INDICATED. ()/, ," 10'9 9 0 OTHER. SPECIFY
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21. SIGNATURE OF GROOM
29. OFFICIANT
NAME (PRINT)
;Vy
DATE blt1/nr
/2.603
STATE
TITLE
SIGNATURE ~
M~NG ADDRE
~R~AH
30. WITNESS TO CEREMONY
NAME (PRINT) ~o
SIGNATURE~
DOH-98 (0312006)
by New York Domestic
MONTH
YEAR
02
2009
30 2009
06
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
.....-:
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF iJ;1'OWN OF 0 VILLAGE OF
SPECIFY ~ J/S, 1fs.J/~/L1.
31. WITNESS TO
NAME (PRINT)
SIGNATURE~