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1 . A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William Auaustus Briehof, Jr
FIRST MIDDLr' CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~~c: 1 368
~~~ltiJ~R 53
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Elizabeth Anne Emard
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Briehof
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURiTY NUMBER 074-70-2976
12 RESIDENCE ANY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Pouqhkeepsie
D. STREET ADDREss29 Sheraton Drive
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)074 72 8113
D SOCIAL SECURITY NUMBER --
2 RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ..tJ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D STREET ADDRESS 29 Sheraton Drive ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"6 NO
O~ / ~1 /1976
MONTH DAY YEAR
ZIP 12601
DYES '6 NO
;(982
YEAR
3. A. AGE ~?
3B. DATE OF BIRTH
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE 25 3B. DATE OF BIRTH 10 Ao
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Medical Billing
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Hartford. Connecticut
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Normand Raymond Emard
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A MAIDEN NAME Cynthia Ann Adamick
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
4. EMPLOYMENT
A USUAL OCCUPATION Lead Carpenter
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH City Of Pouahkeepsie
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME William Allgu~tus Rriehof Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Janine Louise Geneix
B. COUNTRY OF BIRTH France
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUSMARBIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) !!'l DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 08 / 1 8 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 08/18/2005 Poughkeepsie, New York 0 1"'1
2ND 0 0
3RD 0 0
4TH 0
I duly swear/affirm, dep.ose and say, that to the best of my knowledge
as to my right to enter into the marriage st te.
21. SIGNATURE OF GROOM ~
DEATH
o
(2) 0 DEATH
2005
YEAR
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
o
o
23. SUBSCRIBED AND SWORN TO/AFFIRMED B
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
OS/22/2008
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-..t-'
YEAR
YEAR
MONTH
DAY
NAME (PRINT)
TIME
MONTH
09:00AM 05
PM
23
2008
07
21 2008
STATE
27. TYPE OF CEREMONY
o oB'1lELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~-+c..6..e~S'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY Wc.r.ff''''4.y:rs .{:~ lLs
10 CIVIL