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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Patr~JbLPl1iCh::l~1 F1~U~t\URNAME
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided i
as to my right to enter into the marnage state.
21. SIGNATURE OF GROOM~ 6- ~-,---55'7 22. SIGNATURE OF BRIDE~
r ~ jf~RENT NAME ..
23 ~~;.t~~~Do~Nfo~~Oo~ ~~A6r~~E~ BEFORf M~ L ~ 1 C/Jta..; LA>
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
COUNTY Dutchess
CITYrrOWN Wappinger
~~~::oc: 1368
~5~1~~~R 38
1 . A. FULL NAME
FIRST
0.
N
B. BIRTH NAME, IF DIFFERENT
....
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C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER O~4-7?-9~7~
2. RESIDENCE A NYsTATE) B. 9c~~~E'5S
C. CHECK ONE 0 CITY"jlJ TOWN 0 VILLAGE
AND \AI .
SPECIFY ::lrrlno~r
D, STREET ADDRESS 29 Pye Lane ZIP 12590
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0(] NO
3. A. AGE 27 38 DATE OF BIRTH MOQ~ / ot? / y1-wm
4. EMPLOYMENT
A, USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS r.nn~tn Jr.tinn
5. PLACE OF BIRTH Citv Of Pnllnhk~~n!':i~
(CIR STATE / COUNTM' IF NOT USA)
6. FATHER
A. NAME Patrick Allen Barrett
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME SII!':::ln Rein::! nnn~y
B. COUNTRY OF BIRTH I I S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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
0:'
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{SEAL SIGNATURE ~ ~"' r. DATE
MAILING ADDRESS !
'-v-I STR~ Middletlllsh Rd, '^'aP.R~rs F(;jll!':
~~:R~~Ri~~~ IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYp.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0
DATE AND AT THE TIME AND A
PLACE INDICATED. '5 I rJ
29. OFFICIANT
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
](,f/ U
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) i{ [" u I ~ P t"I ~p ~ ~wZ ^ )
SIGNATURE~ )c. +:d- .
DOH-98 (0312006)
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Heather Marie Zeno
MIDDLE CURRENT SURNAME
.-J
11. A. FULL NAME
FIRST
B, BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE R::!rr~tt
(OPTIONAL. SEE REVERSE) 076 68 8082
D. SOCIAL SECURITY NUMBER ___ - __ - _ _
12. RESIDENCE A. NY B. [)utchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY!i1'l TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 29 Pye Lane
13, A. AGE 26
11
MONTH
ZIP 12590
o YES ~ NO
A~R1
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
A~
DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION r.nmmlmity Manager
B. TYPE OF INDUSTRY OR BUSINESS Real Estate
15. PLACE OF BIRTH Cold Sorina, New York
(CITY, STATE / COUNi'RY IF NOT USA)
16. FATHER
A. NAME Rri::ln K~ith 7~nn
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Robin A Raymond
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
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, PROYIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
,al impediment exists
04/~O/?OOR
DATE
by New York Domestic
TIME
MONTH
MONTH
YEAR
YEAR
04/~0/200,
11 :05AM
PM
05
01
2008
06
29 2008
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Ovfc-~ l!SS
A~
,1ir
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY tAr; rtrV1 '
b/
ZIP
31. WITNESS TO CEREMONY '--;--'" ,
NAME (PRINT) VYle.. \\ ~')Cl j \fl' ~\ ,
{y' . t. A J .-r,
SIGNATURE~ ~'-\,
