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21. SIGNATURE OF GROOM~
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23. SUBSCRIBED AND SWORN TO/AFfiRMED BEF
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Slate of the bride and groom named above by any person authorized
Relations Law ~11to 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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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J ~;fK~y D ii1le F !;~~ENT SURNAME
.
c"5lJFJTY nlltr.hF!!=:!=:
CITYITOWN W!=IppingAr
~~~:k~T 1 ~RR
~~~~;~R R7
1. A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 1 31 - Fi ? - 7 Fi? 1
2 RESIDENCE A. N~TATE) B qdd&'Sf~ess
c. CHECK ONE 0 CITY ojl) TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 1?7 r.lnvF! Rr!=lnr.h Rn!=ld ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 4 Q 3B. DATE OF BIRTH MO~ /~? / y1,g59
r
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
4. EMPLOYMENT
A. USUAL OCCUPATION Hea\lY Eq1lipment Ind'lstry
B. TYPE OF INDUSTRY OR BUSINESS Cnn!=:trllr.tinn
5. PLACE OF BIRTH fclg,', ~A7~~otg~Jft\0~XA)
6. FATHER
A. NAME Roy G Frye
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME Arl::l N::lnmi P::lhlr.k
B. COUNTRY OF BIRTH I' S A
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Layna MtffyLynn I ::lJJRi{~~uRNAME
~
1
o
B. HOW DID LAST MARRIAGE END? (3) M DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01/?4 / ?n08 .
MONTH om YE'A!l
D. ARE ANY FORMER SPOUSE(S) ALIVE? IY'YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CrrY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
n1/?A./?nnR n,ltr.hA!=:!=: r.nl mty, NY 0
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11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Bern.rdo
c. SURNAME AFTER MARRIAGE 1= r\le
(OPTIONAL - SEE REVERSE) ]
D. SOCIAL SECURITY NUMBER n7 A.-Rn-~RR!)
12. RESIDENCE A. NY
(STATE)
C. CHECK ONE 0 CITY Iitl
~~~CIFY F!=I!=:t Fi!=:hkill
D. STREET ADDRESS 127 Clove Branch Road ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
QJ.TH /-j ~AY /j' ~E~R3
B~SS
TOWN 0 VILLAGE
13. A. AGE 44
3B. DATE OF BIRTH
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say,
as to my right to enter into the. mama
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{ SEAL }
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NAME (PRINT)
DATE
14. EMPLOYMENT
A. USUAL OCCUPATION l-lomem8ker
B. TYPE OF INDUSTRY OR BUSINESS HnmAm!=lker
15. PLACE OF BIRTH Mnntnnmp.nL Mn
(CITY, S-rnTE / couNlflv IF NOT USA)
16, FATHER
A. NAME Gl1alter Macedl Bernardo
'B. COUNTRY OF BIRTHRr!=l7i1
17. MOTHER
A MAIDEN NAME nnrnthy Hild!=l r.rnr.r.n
B. COUNTRY OF BIRTHl J S A
1B. NUMBER OF THIS MARRIAGE 7
B. HOW DID LAST MARRIAGE END?
C.
D.
DEATH
n
(2) 0 DEATH
/ ?n08
- YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA~l'D.
ITY WN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
M
IlttlO PM 0 0<6
MES D. PAGONES
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1)!t CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY a~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY Ph,\\\ ~ $l-O\Nf'\.
20.
1ST
2ND
3RD
o ~
o I!f
c!' 0
o I!f
pediment exists
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
n6/11/?on8
ZIP
AM
05:58PM
10 2008
06
12
2008
08
NAME (PRINT)
SIGNATURE~
~
...
-CO~NTY
CITYrrOWN
DISTRICT
NUMBER
REGISTER
NUMBER
~ I '" II::. vr I~I::.VY ,vnn. (TH/S SPACE FOR STATE USE ONLYj
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE L 0 SUPPLEMENTAL FILE
-.J
+
/ FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME 11. A. FULL NAME
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
Q. B. BIRTH NAME. IF DIFFERENT
N B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) (OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. B. 12. RESIDENCE A. B
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
AND AND
SPECIFY SPECIFY
D. STREET ADDRESS ZIP D. STREET ADDRESS ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
3. A. AGE 3B. DATE OF BIRTH / / 13. A. AGE 3B. DATE OF BIRTH / /
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT 14. EMPLOYMENT
w
S A. USUAL OCCUPATION A. USUAL OCCUPATION
en
B. TYPE OF INDUSTRY OR BUSINESS B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH 15. PLACE OF BIRTH
(CITY. STATE / COUNTRY IF NOT USA) (CITY, STATE / COUNTRY IF NOT USA)
6. FATHER 16. FATHER
I- A. NAME A. NAME
:;
c( B. COUNTRY OF BIRTH B. COUNTRY OF BIRTH
C 7. MOTHER 17. MOTHER
wU:::
"'u. A. MAIDEN NAME A. MAIDEN NAME
~c( B. COUNTRY OF BIRTH B. COUNTRY OF BIRTH
I B. NUMBER OF THIS MARRIAGE 1 B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGE8 19. PREVIOUS MARRIAGES
u A. NUMBER OF PREVI US MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / ~
MONTH DAY YEAR MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES DNO D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES ONO
~
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 ~ 1'1'10 Pl.'TN.....fY"l (DVr"'\~ 0 ~ 1ST 0 0
2ND O()..IO~llq~a.- we1.tel..{e.sre.cL C'W/1~ ~ 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 marnage state.
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
USE CURRENT NAME USE CURRENT NAME
'" 23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ 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
W 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.
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS 25. B. SOLEMNIZATION PERIOD
W ENDS AT MIDNIGHT ON:
{ SEAL } NAME (PRINT) MONTH I DAY I YEAR MONTH I DAY I YEAR
0 TIME
::i SIGNATURE ~ DATE
MAILING ADDRESS AM
""- '-...-I PM
STREET CITYrrOWN STATE ZIP
/ I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY 2B. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o 0 RELIGIOUS 10 CIVIL NEW YORK
DATE AND AT THE TIME AND A~ I A. STATE B. COUNTY
PLACE INDICATED. PM 9 0 OTHER, SPECIFY
W C. LOCATION OF CEREMONY
~ 29. OFFICIANT (CHECK ONE AND SPECIFY)
0 NAME (PRINT) TITLE
o CITY OF 0 TOWN OF o VILLAGE OF
u::: SIGNATURE ~ DATE
i= MAILING ADDRESS SPECIFY
a:
W STREET CITYrrOWN STATE ZIP
0 30. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
NAME (PRINT) NAME (PRINT)
""- SIGNATURE~ SIGNATURE~
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