126
1ST
2ND
3RD
4TH
I duly swear/affirm, deP.Ose and say, that to the be
as to my right to enter into the mamage state.
21. SIGNATURE OF GROOM~
. MSE URRENT NAME
23. SUBSCRIBED AND SWORN TOIAF MED BEFOR " -' ~ /)- '---t-..--., ~ ~ L' ^
SIGNATUREOFTOWNORCITYCLERK~ _-':~ !:...-f _ ~:!!..._'-::::!!!!l..
This license authorizes the "","age in New York State of the bride and groom named above by any person authorized by New York Domestic
W Relations Law ~11 to pertorm marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
en 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z t-'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W { } NAME (PRINT) John C.
o TIME MONTH YEAR MONTH DAY YEAR
::i SEAL SIGNATURE ~ 9/25/200
'-v-I MAI~ ~aarebU5 5, NY 12590 11 :52AM 09
STREET STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 Gii RELIGIOUS
DATE AND AT THE TIME AND / / 00
PLACE INDICATED. 12 : 0 M 10 6 2 7 9 0 OTHER, SPECIFY
W C. LOCATION OF CEREMONY
!( 29.0FFICIANT Daniel B. Ward Pastor (CHECK ONE AND SPECIFY)
o NAME (PRINT) ~ ~-' ~ ":.# __ ~ /.. JJ TITLE ~:CITY OF 0 TOWN OF 0 VILLAGE OF
~ ~Xr~~1J'~5~"""'~ DATE 10-6-2007 SPECIFY Poughkeepsie
~ St. John's Evangelical Lutheran, 55 Wilbur Blvd., Poughkeeps.e, NY 12603
W STREET CITYfTOWN STATE ZIP
o 30. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
NAME (PRINT) Richar NAME (PRINT) L ri Maida r
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST And~'ttEPeter MCC~RNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~c: 1368 .
~~~I~J~R 126
1 . A. FUll NAME
0-
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER OBO-66-64?7 '
2. RESIDENCE A. N';(TATE) B. ~es~
C. CHECK ONE 0 CITY Wi! TOWN 0 VILLAGE
AND W .
SPECIFY ::!rrlngAr
D. STREET ADDRESS 510 Maloney Road. Apt. ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
3. A. AGE 29 3B. DATE OF BIRTH nQ / 16 / 1 Q78
MOil'fir DAY YEAll
4. EMPLOYMENT
A. USUAL OCCUPATION RII~ nrAr::!tnr
B. TYPE OF INDUSTRY OR BUSINESS T(ansit
5. PLACE OF BIRTH Carmel, New York
(CITY, STATE I COUNTRY iF NOT USA)
6. FATHER
A. NAME Willi::lm F Mr. ~::Irry
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kathleen R. Smith
B. COUNTRY OF BIRTH USA
8. NUMBER OF TIHIS MARRIAGE 1
9. ~~~~~~~RMtFR~~1:~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o O'
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
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF OECREE PLACE ISSUED AGAINSTWHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
SIGNATURE~
DOH.98 (0312006)
I
"I
STATE FILE NUMBER
(rHIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~t::lr.\1 r.hri~tinA Rrin~fjAlrJ
.,.. MIDDLE CURRENT SURNAME
--1
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE I\~C Gcrnl
(OPTIONAL. SEE REVERSE) ....,..
D. SOCIAL SECURITY NUMBER 052-72-8107
12. RESIDENCE A. NY B. nl Jtr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY iii' TOWN 0 VILLAGE
AND W .
SPECIFY applnQer
D. STREET ADDRESS 51 0 Maloney Road. Apt. ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 1!1 NO
13. A. AGE ?1 3B. DATE OF BIRTH OR A 3 A 986
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION E M T
B. TYPE OF INDUSTRY OR BUSINESS Emergencv Medical
15. PLACE OF BIRTH City Of Poughkeepsie. Ny
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME William Hudson Brinsfield Jr.
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nancy Jayne Groton
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
1ST
2ND
3RD
4T
at the information I provided is true
o
o
o
22. SIGNATURE OF BRIDE ~ .
25. B. SOLEMNIZATION PERIOO
ENDS AT MIDNIGHT ON:
25
2007
23 2007
11
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Dutchess
SIGNATURE~