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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JOSiBtELouis T8!~~SURNAME
COUNTY Dlltche5'5
CITYfTOWN \NappinOAr
~~~~~CRT 1368
~~~~;~R 69
1 . A. FULL NAME
FIRST
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N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 054-58-5191
2 RESIDENCE A. N);;TATE) 8. ~~8SS
C CHECK ONE 0 CITY 0 TOWN IilJ VILLAGE
~~~CIFY Filthkill
o STREET ADDRESS 1609 M::lY \N::lY ZIP 1 ?fi?4
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Iii'! YES 0 NO
MO~ / Ji;3 / y1i73
3. A. AGE 35
4. EMPLOYMENT
3B. DATE OF BIRTH
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A. USUAL OCCUPATION Corr~ction Offic~r
B TYPE OF INDUSTRY OR BUSINESS La'^' Enforcement
5. PLACE OF BIRTH Port Chester Ne'^' York
(CITY, STATE / COUNTRv'1F NOT USA)
6. FATHER
A. NAME Not Liited
B COUNTRY OF BIRTH Not Listed
7, MOTHER
A. MAIDEN NAME Carolyn \Nilson
B. COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE ?
9. PREVIOUS MARRIAGES
A. NUMBER OF F'RE.VIOUS MARRIAGES.WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) ISi'f DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03/ ne / ?n07
MONTH Dt!; YrA'!!i
D. ARE ANY FORMER SPOUSE(S) ALIVE? [Y"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
1ST 03'06'2007 POllghkeepsie, Nell\! York
2ND
3RD
o
o
o
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mal..lreElt'D&ili~ilbeth l;aJ"rQW~NAME
--.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~t~M~~~rt~~~~sJ;"81~sco
D. SOCIAL SECURITY NUMBER nFi~-RR-RRR 1
12. RESIDENCE A, NY 8. D"t"+U:'Slt
(STATE) (C~
C. CHECK ONE 0 CITY 0 TOWN t;i!l VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 1 on!=) M~)( W~y ZIP 1 ?fi24
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE? oItJ YES 0 NO
13 A AGE 26 3B, DATE OF BIRTH Q~TH /()~Y -1 ~R1
14. EMPLOYMENT
A, USUAL OCCUPATION Retail Manager
B. TYPE OF INDUSTRY OR BUSINESS RAt::lil
15, PLACE OF BIRTH MOllnt Kic:::~n NAW Ynrk
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
,A. NAME Chrilttopher Ii 1lillS Bro'^'ne
B. COUNTRY OF BIRTHI J S A
17. MOTHER
A. MAIDEN NAME nonn;:! M::lriA r.hArt Ihini
B. COUNTRY OF BIRTH I J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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
2ND
3RD
o 0
o 0
o 0
o 0
legal impediment exists
21. SIGNATURE OF GROOM~
22. SIGNATURE OF BRIDE ~
)~
no/1 ~/?nnR
23. SUBSCRIBED AND SWORN TO MED BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
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
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{ SEAL }
'-v-'
NAME (PRINT)
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
OATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
DATE
f (~ "-
I
STA E
TIME
MONTH
YEAR
MONTH
YEAR
11 :28AM
PM
2008
08
12 2008
06
14
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY 1)v...1t.l~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ('g. TOWN OF 0 VILLAGE OF
SPECIFY
nS~Iu..
31.
NAME (PRINT) '-
SIGNATURE~