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COUNTY Dutchess
CITYfTOWN Wappinqer
~~~:~c~ 1368
~5~1:~~R 84
~ I #4. I C Vr" I~C VV J vnl'\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William Michael Murin
MIDDLE CURRENT SURNAME
FIRST
(TH/S SPACE FOR STATE USE ONL YI
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ashle~IIM.~chelle Hec~~~XTksuRNAME
1. A FULL NAME
11. A FUll NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE M u ri n
(OPTIONAL - SEE REVERSE)064_68_7304
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STA1J') (COUNTY)
C. CHECK ONE 'rJ CITY 0 TOWN 0 VilLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 1404 Holly Walk
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 5 1
D. SOCIAL SECURITY NUMBER 06-62 - 86
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY PouQhkeepsie
D STREET ADDRESS 1404 Holly Walk ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
04 / 11 / 1979
MONTH DAY YEAR
ZIP 12603
'6
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 24 3B. DATE OF BIRTH 09 /11
MONTH DAY
YES 0 NO
)1'983
YEAR
3. A. AGE 29
3B. DATE OF BIRTH
l-
S;
~
c
wi!
~u..
-<(
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
5. PLACE OF BIRTH City Of PouQhkeepsie
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Gregory Michael Murin
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kathleen Mary Hand
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
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH City Of Poughkeepsie, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Michael Joseph Hendryk
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Christine Theresa Pacio
B. COUNTRY OF BIRTHU S A
1B. 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 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
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
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 ,}rte,. AI'
21. SIGNATURE OF GROOM~ ,~~ /IUvu;" 22. SIGNATURE OF BRIDE~ .
~SE RRENT NAME ~ ... SE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEF E . A _ ' . /J A / A
SIGNATUREOFTOWNORCITYClERK~ ~ <U-~.c.."-" 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
} NAME (PRINT) John .
{ 7/09/2008 TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~
'-.t-I MAI~~~~8f~b d, Wappinge s F:3l1s, NY 12590 03:09;~ 07 10 2008 09 07 2008
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27~TYPE F CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ELlGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND AM C
PLACE INDICATED. ,'.3.0 M 0 Z. Or 9 0 OTHER, SPECIFY
~~~tj~~~~ fJ7S'Gl!. he~c(s ? 1J~L.LEw TITLE ~ C. {kl?sr
SIGNATUR~~~~~r f~f? ;S~ 9/.;t/()s
MAlLIN; AD~ 4t: uJ. ~ .'9df.a . , I a
STREET CITYfTO
30. WITNESS TOBJ:REMONY
NAME (PRINT) l\ev I.' M lJ. (11'\
SIGNATURE~ ~'l~~. ~
DOH-98 (0312006)
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couN~"'\ti'fE'S5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY WAA9It.J6ERJ JA..u.s
NAME (PRINT)
SIGNATURE~