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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel James CreaQh
MIDDLE CURRENT SURNAME
USE
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 !l11 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
n
COUNTY Dutchess
CITYITOWN Wappinger
~~~:~CRT 1368
~5~I;J~R 16
1. A FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl069_54_8150
D SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY 8. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0(] TOWN 0 VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 11 B Canterbury Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
10 /31 /1959
MONTH DAY YEAR
3. A AGE 49
38. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Retired Policeman
B. TYPE OF INDUSTRY OR BUSINESS Law Enforcement
5. PLACE OF BIRTH Queens, Ny
(CITY, STATE / COUNTRY IF NOT USA)
....
:;
6. FATHER
A NAME James Creagh
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Anna Barrett
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
DEATH
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
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
o
o
o
21. SIGNATURE OF GROOM ~
~
{ SEAL }
~
NAME (PRINT)
SIGNATURE ..
MAILING ADD
20 Mi 01
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
.J
FROM THE BRIDE
Renee Ware
FIRST MIDDLE CURRENT SURNAME
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT Renee Bastian
c. SURNAME AFTER MARRIAGE CreaQh
(OPTIONAL - SEE REVERSE)067 -44-2726
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
D :~:~~A:R:~~;n~~anterbUry Lane
11. A. FULL NAME
ZIP 12590
DYES r'J NO
/f950
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 58 3B. DATE OF BIRTH 07 ~O
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Housewife
B. TYPE OF INDUSTRY OR BUSINESS Homemaker
15. PLACE OF BIRTH Manhattan, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Alfonzo Bastian
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A MAIDEN NAME Bernice Williams
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
o
o
o
B. HOW DID LAST MARRIAGE END? (3) d'DlVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 11 / 2009
MONTV DAY" YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ['J 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
1ST 03/11/2009 Poughkeepsie, Ny 0 d'
2ND 0 0
~ 0 0
o 0
d that I ~eclare thw~nl exists
USE CURRENT NAME
DATE
04/02/2009
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
08:45AM
PM
04
03
2009
06
01 2009
~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNr2b1 ;./tt!w5S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
29. OFFICIANT
NAME (PRINT)
TITLE _~i p"'-,OS ~fl (.:p I
o VILLAGE OF
SIGNATURE ..
MAILING ADDRES
~' -
STREET CITYIT
M. W","" ro 'r:1"
:::::::: ~:Y;ft: ~~O~~'"'Y\
DOH-98 (03/2006)
SPECIFY
ZIP
" ..",,, ro ~m .-(
NAME(PRINT)f ~
SIGNATURE"
~~e
.,/