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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 I OIIb'?D~ir.hnl~s PJlj~~U~ SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~: 1368 .
~~~I~~~R 125
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nir.n~@D~~hley Pa~~~NT SURNAME
11. A. FULL NAME
FIRST
c.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE P A rill n
(OPTIONAL - SEE REVERSE)126 76 6595
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE AN V B.DlJtche~s
(STATE) (COUNTY)
C. CHECK ONE 0 CITY otI TOWN 0 VILLAGE
~~CIFY Poughkeepsie
D. STREET ADDREss6 Wennington Drive
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ,
D. SOCIAL SECURITY NUMBER 103-72-6206
2. RESIDENCE A. N V B. nlltchA~~
mATE) (COUNTY)
C. CHECK ONE 0 CITY..z:J TOWN 0 VILLAGE
~~~CIFY Fa~t Fi~hkill
D. STREET ADDRESS 46 Julie Drive ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES olJ NO
3. A AGE28 3B.DATEOFBIRTH 1? /31 /197R
MON'l'H DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?1 3B. DATE OF BIRTH 09 ,.05
. MONTH DAY
ZIP 12603
o YES'6 NO
;(q86
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION FIAvatnr r.nn~tn Idnr
B. TYPE OF INDUSTRY OR BUSINESS Fuji Tech
5. PLACE OF BIRTH Citv Of Pouqhkeeo.sie
(ci'Ft STATE I couNTlfy IF NOT lISA)
6. FATHER
A. NAME I OIli~ PArilln
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Louise Janet Renta
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Receptionist
B. TYPE OF INDUSTRY OR BUSINESS Dr. Leslie Brusie
15. PLACE OF BIRTH Chester. Pennsylvania
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Payne
'B. COUNTRY OF BIRTJ.! S A
17. MOTHER
A. MAIDEN NAME Nancy Pierce
B. COUNTRY OF BIRTHU 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
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
." - YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.Dse and say, t
as to my right to enter into the ma
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
my knowledge and belief thatlhe information I provided is true and that
o
o
o
USE cu
IRMED BEFORE ME
CLERK ~
This license authon es the marriage in New York State of t
Relations Law !jllto perform marriage ceremonies within New York S e. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used 0 Iy for the purpose of a second or subsequent ceremony.
r-"'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo n C. Ma ter: on
C TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 09/20/2007
~ MA~5G~cfaf~ sh Rd, in ers Falls, NY 12590
STREET CITYITOWN STATE ZIP
~~~R~~RT~~~ 'o~O~~~N~EE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 !:S/RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 90 OTHER, SPECI
DATE
by New York Domestic
MONTH
YEAR
01 :38 ~~ 09
11
19 2007
21
2007
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY6+-~
C. LOCATION OF CEREMONY I -
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN ~ ~ "!hE ?j
SPECIFY S 1 ~ r. '11