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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
8ciaPeatrick T ~IfMNT SURNAME
COUNTY Dutchess
giii~g.WN Wappinger
~~~~~~J 368
NUMBER 133
1 . A. FULL NAME
FIRST
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B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL" SEE REVERSE)
o SOCIAL SECURITY NUMBER 113 60 0351
2 RESIDENCEA. N\~TATE) B. Q~pOG
C. CHECK ONE 0 CITY 0 TOWNJ] VilLAGE
AND
SPECIFY Wappingers Falls
o STREET ADDRESS "1 Park St; Apt 1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? .eJ YES 0 NO
MJ;!i / ae / ~m1
3. A. AGE 37
4. EMPLOYMENT
3B. DATE OF BIRTH
A USUAL OCCUPATION Cablcvision T eohnioi:m
B. TYPE OF INDUSTRY OR BUSINESS Telecommunicationi
5. PLACE OF BIRTH ~tffl~ ~
( , :rt I NTRY IF NOT USA)
6. FATHER
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A. NAME Jeffcry Martin Taylor
B. COUNTRY OF BIRTH U a A
7. MOTHER
A. MAIDEN NAME S:mdra L. HaAZucha
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
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Clar~i~.nn& S&~/;lNT SURNAME
~
11. A. FULLNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~S~~~Mrr~~~t~~C~~sT,aylor
D. SOCIAL SECURITY NUMBER 1 08-68-8505
12. RESIDENCE A NY(STATE) BD~ss
C. CHECK ONE 0 CITY 0 TOWN oJll VilLAGE
~~~cIFY'^'appingers Falls
D. STREET ADDRESs4 P::Irk ~t: Art 1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? olJ YES 0 NO
13. A. AGE31 3B.DATEOFBIRTH ~~H /()~AY -1~l.Z
14. EMPLOYMENT
A. USUAL OCCUPATION Data Entry
B. TYPE OF INDUSTRY OR BUSINESS Nnn-rrnfit
15. PLACE OF BIRTH Yc~ ~W!e1 COtlJRY IF NOT USA)
16. FATHER
A. NAMERob8rt Francis Sexton
'B. COUNTRY OF BIRTHI I S A
17. MOTHER
A. MAIDEN NAME Rit~ POrTIr::l
B. COUNTRY OF BIRTHI I B A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o
o
DEATH
n
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
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
o
o
o
22. SIGNATURE OF BRIDE ~
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1ST
2ND
3RD
4TH
I duly swear/affirm. depose and say,
as to my right to enter into the marn
21. SIGNATURE OF GROOM ~ -
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
knowledge and belief that the information I provided is true
23. SUBSCRIBED AND SWORN TO/AFFIRMED
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y. rk State of the bride and groom named above by any person authorized
Relations Law ~11 to perlorm 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
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{ SEAL }
'-..,-I
NAME (PRINT)
DATE
DATE 09/10/2008
by New York Domestic
TIME
MONTH
YEAR
DAY
MONTH
YEAR
AM
04:42PM
09
11
2008
11
09 2008
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER"
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYP,7DF CEREMONY
o MEllGIOUS
9 0 OTHER, SPECIFY
10 CIVil
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY}umlfCSr
29. OFFICIANT /I1S6-1?
NAME (PRINT) ,
SIGNATURE ~ lJiL
MAILING ADDRESS
I
STREET
30. WITNESS TO CEREMONY
~JtItoNr:
TITLE
NAME (PRINT)
SIGNATURE~
DOH-9B (03/2006)
~. ~ Pl2lfS"'
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF 12fVllLAGE OF
SPECIFY WltPAIlGG2S htas
I "2-.J~ 0
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ""R! (~ Cf'ltJ.
SIGNATURE~ ~...t.AL
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