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COUNTYDutchess
CITYfTOWN\Mappinger
DISTRICT ..
NUMBER~gg
REGISTER'"
NUMBER 14 3
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
\NillioItThJad'II::lrd Br~Q~YuRNAME
:; I A I t: ~ILt: NUM~t:H
(TH/S SPACE FOR STA TE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
lal1~U~crnl GII=!~JRRENT SURNAME
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
II.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTVV.de
C svs~~ttM~~~~EA~~~~~jJra n d a LI
D. SOCIAL SECURITY NUMBER 04~-40-~424
12. RESIDENCE ANY B.[)lltr.hl=!!':!':
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND P hk .
SPECIFY nllO p.p.r~le
D. STREETADDREss14 Flamingo Drive
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGF44 3B. DATE OF BIRTH 01 ,11
MONTH DAY
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 1 02 42 21 03
2 RESIDENCE A. N~STATE) B. UJ~t~)
C. CHECK ONE 0 CITYJJ TOWN 0 VILLAGE
AND
SPECIFY Plattekill
o STREET ADDRESS 160 Camp Sllnset Road ZIP 1 ?Fi?R
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEs.{] NO
M~ /~.l / ~~~6
ZIP 12601
o YES~ NO
j(qR4
YEAR
3. A. AGE 52
4. EMPLOYMENT
3B. DATE OF BIRTH
14. EMPLOYMENIT
A. USUAL OCCUPATIONNllr!':1=!
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTHH::irtford, Ct
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME\^'illia/Tl Thom::J!': W::irll=!
'B. COUNTRY OF BIRnU S A
17. MOTHER
A. MAIDEN NAME Carol Theresa Myers
B. COUNTRY OF BIRTI.jJ S A
1B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
A. USUAL OCCUPATION Superintendent
B. TYPE OF INDUSTRY OR BUSINESS Apartment Maint
5. PLACE OF BIRTH~rlicott 1\.111
~rtr. ~"'A.,.~nduMRY IF NOT USA)
6. FATHER
A. NAME Robert Richards Brandau
B. COUNlTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jun& Eil&ne Bahner
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
DEATH
o
DEATH
o
o
o
W
en
z
W
o
::l
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) r!'l DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 03 / 03 / 2008
MONTH DAY YEAR MONTH DAY, ',- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? I!1YES 0 NO
~
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 (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 03103/?008 Poughkeepsie, Ny 0 1!1
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 IT)arnage st~te. ~ . ~
21. SIGNATURE OF GROOM ~ f:. 22. SIGNATURE OF BRIDE ~ ~-
U USE CURRENT NAME
23 ~::J:T~~~Do~N.fo~~~~N~~A6r:rR~E~ BEFORE M DATE 09/24/2008
This license authorizes the marriage in New by New York Domestic
Relations Law ~11 to perform marriage ceremoni 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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
,-I'-..
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
DAY
YEAR
YEAR
TIME
MONTH
AM
04:44PM 09
25
2008
11
23 2008
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY /JJ)TC.J,ESS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~~ IJ J(upsrE..
30. WITNESS TO ~EMONY ./2
NAME (PRINT) V \A 5 ().. V\ h... 1-:) R 1\ JJ .J)A LA..
SIGNATURE~ ~d--., (~
DOH-98 (03/2006)
NAME (PRINT)
SIGNATURE~