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:s I A II:. UI- NI:.W YUHK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian David Burk~
MIDDLE CUR ENT SURNAME
COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~c~ 1368
~~~~;~R 1 56
1 . A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 9 8 4576
D. SOCIAL SECURITY NUMBER 05 -4 -
2. RESIDENCE A. NY B. Dutchess
(ST A IE) (COUNTY)
C. CHECK ONE "0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
o STREET ADDRESS 55 Dogwood Lane ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
3. A. AGE 47 3B. DATE OF BIRTH 11 / 02 /1960
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Correction Officer
B. TYPE OF INDUSTRY OR BUSINESS Corrections
5. PLACE OF BIRTH Beacon, NY
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Joseph Martin Burky
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Rose Elizabeth DiRubbio
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
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Dawn Marie Minnerly
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT M u h I ba u e r
c. SURNAME AFTER MARRIAGE Burkv
(OPTIONAL. SEE REVERSE)099_62_8946
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 150 Hudson Harbor Dnve
11. A. FULL NAME
ZIP 12601
o YES'6 NO
;1'964
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE44 3B. DATE OF BIRTH 04 ~O
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Correction Officer
B. TYPE OF INDUSTRY OR BUSINESS Corrections
15. PLACE OF BIRTH Mount Kisco, Ny
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Derek R. Minnerly
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Renata K. Muhlbauer
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 2
o
o
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDEO BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 6 DIVORCE (3) 0 ANNULMENT (210 DEATH
C. DATE LAST MARRIAGE ENDED? 1 0 / 06 / 19~4
MONTI1,oo DAY, - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? CJ 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
10/06/1994 White Plains, Ny r5
DEATH
o
1ST
2ND
3RD
0:'
W
III
::;
::l
Z
o
z
<
tii
~
"'
1ST
2ND
3RD
4TH
I duly swear/affirm, aep'ose and sa , that to the best of m
as to my right to enter into th~ lag,e state. \..
21. SIGNATURE OF GROOM'- L.J.
USE CU
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New' Y State of the bride and groom named above by any person authorized
Relations Law ~11 to pertorm 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 n C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 10/03/2008
\- -.J MAIJ,Jt:l.G ;'~IPjE;i?eS AM
-v- LU IV! uOl ush Rd, Wappingers Falls, NY 12590 03:01 PM 10
STREET CITYITOWN STATE ZIP
~~~~~Ri~~J 10~0~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND AM
PLACE INDICATED. PM 9 0 OTHER. SPECIFY
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
CITYfTOWN
61../0./
/'() - j \:)1"
o
o
22. SIGNATURE OF BRIDE
by New York Domestic
MONTH
YEAR
04
2008
12
02 2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~