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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Patri~DIJmothy DHQil~[URNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
COUNTY n I Jtr.h e~~
CITYITOWN Wappinger
~~~:~136R .
~G~~~~R13?
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
laimlflID~J'trir.ia Pa~~~~~lT SURNAME
--1
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~JNi~~~~t~~C~~~llm~er
D. SOCIAL SECURITY NUMBER 120-64-7534
12. RESIDENCE ANY B nlltr.he~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFYFa!=:t Fi!=:hkill
D. STREET ADDRES~6B Miller Hill Road
ZIP 12533
o YES..n NO
~Rn
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ?n-64-~6?~
2. RESIDENCE A. NY B. nllt,.hess
(STATE) ~)
C. CHECK ONE 0 CITY.,n TOWN 0 VILLAGE
~~~CIFY Fa~t Fi~hkill
D. STREET ADDRESS 36R Miller Hill Road ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..t] NO
M~ / ;!A~ /lil~1
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE27 3B. DATE OF BIRTH 04 AQ
MONTH DAY
3. A. AGE26
4. EMPLOYMENT
A. USUAL OCCUPATION Polir't=! Offir't=!r
B. TYPE OF INDUSTRY OR BUSINESS I aw Fnforr.ement
5. PLACE OFBIRTHRronx~ New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME lam':>5 l\Air'hat=!1 nllm~t=!r
B. COUNTRY OF BIRTH I J R A
14. EMPLOYMENT
A. USUAL OCCUPATIONRt;:)ti~tir.al Analyst
B. TYPE OF INDUSTRY OR BUSINESsAssessment
15. PLACE OF BIRTHOnondaaa. NY
(CITY, STATE I~NTRY IF NOT USA)
16. FATHER
A. NAME. lame!=: Farrell Pardue
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Patricia Ann McDermott
B. COUNTRY OF BIRTJJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
-DIVORCE CIVil ANNULMENT
o 0
DEATH
o
7. MOTHER
A. MAIDEN NAME nehorah Marie Morley
B. COUNTRY OF BIRTH I J R A
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~!S~;~/:f!&i8.USJMRR~~B~;fIf~~u~~W?~Ln.-
n n
-DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEAJH
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. -.- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
22. SIGNATURE OF BRIDE ~
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, tha
as to my right to enter into the mam
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
edge and belief that the Information I provided is t
D
o
o
USE U
23. ~~:~~~Dor.fo~";:;06'~ ci~Abr:r~:~ BEFORE ME DATE 10/03/2007
This license authorizes the marriage in New he bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies . in 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
} NAME (PRINT) J C. M
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE 10/03/2007
\....- .-J MA!l.I.t:!G,.~IDfl~~S AM
-v- :lU Miami in ers Falls, NY 12590 05:09 PM 10 04 2007 12 02 2007
STREET CITYITOWN STATE ZIP
~~R~:Ri~~J 10~0~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 l'B RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. I :00 PM 10 4007 90 OTHER, SPECIFY
29'OFFICIANTt~ v.' ,_ () f\ 11[' (Jr~ 1-
NAME (PRINT) .~~( t\f?\i\ ~ TITLE I<o.tIw1 .t ~ ,'- r; I br
SIGNATURE~---,- ___ ~ DATE /D. b Z()fJl
MAILING ADDR S ,..,
11 eLIN'ioN ~r LJ A-DPINCG-Rt FA-tLJ N V 19-. ~ qe
STREET CITYITOWN STAT'E ZIP
30. WITNESS TO CEREMONY 31. WITNESS TO CERE ONY,
YEAR
10 CIVil
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYJ)Vid-lES'<;;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 lOWN OF 'lX1 VILLAGE OF
SPECIFYWR-~"JN482 So FA-LL~
NAME (PRINT)
SIGNATURE~
OOH-98 (0312006)
NAME (PRINT)
SIGNATURE~