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COUNTY nlltr.hp.!=;!=;
CITYfTOWN Wappinger
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~~~I~~~R 57
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian SMlJ~hael Hen;]~~-&9~URNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
S~m;:mth;::! Ann 7ih lr.k
MIDDLE CURRENT SURNAME
I
~
1. ,A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE I-Iembrook
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 601-24-9969
12 RESIDENCE A.CT B I itr.hfiF!lrl
(STATE) (COUNTY)
C CHECK ONE 0 CITY eJ TOWN 0 VILLAGE
~~~CIFY New Milford
D STREETADDREss166 Malletts Lane
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 041-R?-?47?
2 RESIDENCEA. C1STATE) B L(~~\d
C CHECK ONE 0 CITY .lJ TOWN 0 VILLAGE
~~~CIFY NF!W Milfnrrl
D STREET ADDRESS 1 R6 MalleUs lane ZIP 06776
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES>(J NO
MOQ~ / ~ / ~~R81
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
~4
DAY
13. A. AGE 22
3B. DATE OF BIRTH
nq
MONTH
3. A. AGE 27
4. EMPLOYMENT
A. USUAL OCCUPATION Site SIIpervi90r
B. TYPE OF INDUSTRY OR BUSINESS P~rk!=; Anrl RF!r.rF!ation
5 PLACE OF BIRTH \~{';,t:;[T~~ ~~NT~J NDT USA)
6. FATHER
3B. DATE OF BIRTH
14. EMPLOYMENT
A, USUAL OCCUPATION I-I::!ir~tyli~t
B. TYPE OF INDUSTRY OR BUSINESS Beauty
15. PLACE OF BIRTH Phoenix Arizona
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME M~rk F\I~n 7ih lr.k
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Robin Kelly Fowler
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
A NAME Palll william Hembrook
B. COUNTRY OF BIRTH II S A
7, MOTHER
A, MAIDEN NAME P~trir.i~ PF!r~ir.hF!tti
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
ZIP06776
o YES~ NO
/1' qRFi
YEAR
DEATH
n
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
B. HOW OlD 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
0:
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is 1r
as to my right to enter into the marnage statj3, ~
- /
21. SIGNATURE OF GROOM 22. SIGNATURE OF BRIDE~
o 0
o 0
o 0
o 0
lare th~ediment exists
USE CURRENT NAME
W
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23. SUBSCRIBED AND SWORN TO/AFFIRMED
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 " 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
DATE
by New York Domestic
06102/2008
YEAR
MONTH
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
DAY
YEAR
~
{ SEAL }
'-.t-I
NAME (PRINT)
TIME
MONTH
11 :48 AM 06
PM
03
2008
08
01 2008
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~1C~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
C. lOCATION OF CEREMONY
(CHECK ONE AN~PECIFY)
o CITY OF~TOWN OF 0 VILLAGE OF
SPECIFY ".; ~PI it::€'tN1J
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) '..Au?+l~~~~
SIGNATURE~ ~