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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~crJ1368
~~~~~~R 1 3
~ I A I ~ UI- N~W YUH~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel Patrick Lynch
MIDDLE CURRENT SURNAME
FIRST
(TH/S SPACE FOR STA TE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Lynn Jones
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
Q.
N
8. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE L ynch
(OPTIONAL - SEE REVERSE124_60_0497
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANY BDutchess
(STATE) J-. (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
~~~CIFYFishkill
D. STREET ADDRESS1 C Half Moon Rd
o YES~ NO
)977
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 6 0300
D, SOCIAL SECURITY NUMBER 113-5-
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..o TOWN 0 VILLAGE
~~~CIFY Fishkill
D STREET ADDRESS 1 C Half Moon Rd ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'tJ NO
11 /17 /1975
MONTH DAY YEAR
12bm:!
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE31 3B. DATE OF BIRTH 04 ))'3
MONTH DAY
3 A. AGE :l:l
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS AdvertisinQ
5, PLACE OF BIRTH Middletown. Ny
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Cyril Patrick Lynch
B. COUNTRY OF BIRTH USA
7, MOTHER
A. MAIDEN NAME Bonnie Lee Sawyer
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
n 0
14. EMPLOYMENT
A. USUAL OCCUPATION Vet Assistant
B. TYPE OF INDUSTRY OR BUSINESS Veterinary
15. PLACE OF BIRTH Bronx, Ny
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Kenneth Jones
. B. COUNTRY OF BIRTJ:! S A
17. MOTHER
A, MAIDEN NAME Patricia Elizabeth Graham
B. COUNTRY OF BIRTJ:! S A
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?
(3) 0 ANNULMENT
/ /
(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
1ST 0 0 1ST 0 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 say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marriage state. _/? ~ -
21. SIGNATURE OF GROOM ~ ~ "L 22. SIGNATURE OF BRIDE ~ - - "-.
USE ~ CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME ,./,,,...,, 03/20/2009
SIGNATURE OF TOWN OR CITY CLERK ~ r..../(f r-- DATE
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
~
{ SEAL }
"-v-I
on
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
YEAR
DATE 03/20/2009
ers Falls NY 12590
WN STATE ZIP
27. TYPE OF CEREMONY
o ijt'RELIGIOUS
9 0 OTHER. SPECIFY
10:55AM
PM
03
21
2009
05
19 2009
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY~"'Clc.~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) .~ q '-.If .L~.c..<?-
SIGNATURE~ ~
DOH-98 (03/2006)
:Tr\
TITLE Pa.S h~
DATE~ J ~ I 0 ,
~ I l..9 '8
STA E ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) .~~ \}'\~Y'\G
SIGNATURE~ L V ~
IX CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY~-c::AC 0 n