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COUNTY Dutchess
CITYrrOWN WappinQer
~~~:~c; 1368
~~~~~~R 1 8
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Micl1~fu,lE In~prh Pddm~I!URNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Caro~~LEBrenda L~~~~TSURNAME
~
1 . A. FULL NAME
11. A FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AffiR MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ???-44-fi474
2 RESIDENCE A. N'lsTATE) B. qdd~~less
c. CHECK ONE 0 CITY <lJ TOWN 0 VILLAGE
AND 'AI .
SPECIFY cprlnopr
D. STREET ADDRESS ~ Rky Tor Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'!""J NO
3. A. AGE 51 3B. DATE OF BIRTH MOg~ / D17 / y1i56-
4. EMPLOYMENT
A. USUAL OCCUPATION Hospital Administrator
B. TYPE OF INDUSTRY OR BUSINESS Hp~lth r.~rp
5. PLACE OF BIRTH '^liImin.nton npl~w~rp
(CITY, STATE'i'COUNTRY IF NOT USA)
6. FATHER
A. NAME Jam8i Michael Purnell
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A MAIDEN NAME Estella \/olk
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE ?
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Pllrnpll
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 095-68-0308
12. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY i!'J TOWN 0 VILLAGE
AND W .
SPECIFY appmQer
o STREET ADDRESS 3 Sky Top Drive
13. A. AGE 40
3B. DATE OF BIRTH
ZIP 12590
o YES~ NO
/f ~R7
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
Ofi /17
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Fnnn Ann Rl'werage Director
B. TYPE OF INDUSTRY OR BUSINESS Hospitality
15. PLACE OF BIRTH Yonkers, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME r,pr(=llrl Fnw~rn I p.wi~
B COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Rllsan Margaret Buckley
B. COUNTRY OF BIRTH l J R A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
1
o
o
B. HOW DID LAST MARRIAGE END? (3) !tI' DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 06/ 15 / ?n07 '
MONTH DAV ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? i:i"VES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? OA. / ~O / ?001
MONTH DA Y ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? i:Y"vES 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 04/30/'001 Pnllohkp.p.r~ip., Np.w Ynrk 0
~D 0
3RD 0
D"
1
1ST 06/15/2007 Poughkeepsie, New York
2ND
3RD
4TH
o
o
o
eZfAJ'Ju u)
W
U)
Z
W
o
::i
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relatipns Law ~11 tD 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
25. 8. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME MONTH YEAR MONTH DAY YEAR
AM
01 :48PM 03 19 2008 05 17 2008
A
27. TYPE OF CEREMONY 28. PLACE WHERE MARRIAGE OCCURRED
o 0 RELIGIOUS 1.Q--cIVIL NEW YORK B. COUN~uTc..~~r.l'
A. STATE
9 0 OTHER, SPECIFY
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
Y 70i'
~ A:;""''f..J
JO ~?
~~4c.o~
CITYfTOWN
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
Ia""cITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY 3~AJ (..0,/
29. OFFICIANT ~. ~ {i.
NAME (PRINT) - t'\ '.Z.
SIGNATURE ~ /_
~AILlNG ADDRESS ". -
1,6. J'~ f;'y
STRE
30. WITNESS TO CEREMONY
TITLEC,.r,. Co'H../ J\lJ~-<-.
r .
DATE ~1A.tr
/V - "( /.,1 rO;:;
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
DOH-9B (0312006)
NAME (PRINT)
SIGNATURE~