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COUNTY Dutchess
CITYfTOWN \Mappinger
DISTRICT . .
~~~~~R 1368
NUMBER 95
.wi I "" I &;;. ur I"~.. . un"
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
B~@ Marl< GI~NTSURNAME
(IH/~ ~I'A(.,.t: rUH ~IAIt: u~t: UNLYj
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Erin ~[istine Pa!Eif;;~H SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE f"" lassnatricl<
(OPTIONAL - SEE REVERSI!l-' I""
D SOCIAL SECURITY NUMBER 338 76 g212
2. RESIDENCE A. III B. I~~on
F ~ST ATE) '1i5OUlm'r
C. ~~5CK ONE 0 CITY ~ TOWN 0 VILLAGE
SPECIFY North Liberty
o STREET ADDRESS 192 South Park Ridge RoactlP 52317
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MO~ / ~1 / y1.~83
C. SURNAME AFTER MARRIAGE ~loGG"'otricl<
(OPTIONAL - SEE REVERS~ I""
D. SOCIAL SECURITY NUMBER 246-69-0853
12. RESIDENCEA.I^(STATE) B. J~~n
C. CHECK ONE 0 CITY Q TOWN 0 VILLAGE
~~~CIFY North Liberty
D STREET ADDRESS 192 SOllth Park Rirloe RnBrl ZIP Fi?~ 17
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES III NO
~TH /1 ~AY /-f ~~
3. A. AGE 25
4. EMPLOYMENT
3B. DATE OF BIRTH
13. A. AGE 23
14. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Chaf
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
5. PLACE OF BIRTH -f;~~~Nll#g~USA)
6. FATHER
A. USUAL OCCUPATION Stage Manager
B. TYPE OF INDUSTRY OR BUSINESS Theater
15. PLACE OF BIRTH ~~;~R:~~OiRS~RJ~USA)
16. FATHER
A. NAME Kennith Daniel Patrick
B. COUNTRY OF BIRTH IJ S A
17. MOTHER
A. MAIDEN NAME Jennifer Lee Dreher
B. COUNTRY OF BIRTHVeneZllela
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
A. NAME Mark {'.lIon Glom;
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Sandra Gerd Stromsland
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
o
o
(2) 0 DEATH
o
o
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END?
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
W
en
z
W
(,)
::i
1ST 0 0 1ST
2ND 0 0 2ND
~ 0 0 ~
4TH 0 0 4TH
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 decare tha
as to my right to enter into the m~. ~ '
21 SIGNATURE OF GROOM~ r r --- ----- ~ - 22. SIGNATURE OF BRIDE~
~c ENT NAME L/? ..
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME "11 A' '4/},JI / A
SIGNATURE OF TOWN OR CITY CLERK. l_ ~_!!. ~4..!:L
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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
o 0
o 0
o 0
o 0
no legal impediment exists
,
DATE
by New York Domestic
~
{ SEAL}
~
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
27 2008
07
30
2008
09
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~~Tt~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./"
o CITY OF 0 TOWN OF Ill"'VILLAGE OF
SPECIFY u)~f'/~ ~
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE.
DOH-98 (D3I2oo6)
NAME (PRINT)
SIGNATURE.