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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~h~Wl P~trir.k ~~~~rX SURNAME
1ST D D 1ST D D
2ND D D 2ND D D
3RD D D 3RD D D
~ D D ~ D D
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal Impediment eXists
as to my right to enter into the r ge state. /J ~ (_.
21. SIGNATURE OF GROOM ~ r. 22 SIGNATURE OF BRIDE ~ . ~ a ~ ~
U URR USE CURRENT NAME
23 SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M 09/05/2007
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New State of t e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
n C. Masterson
C. DATE 09/05/200
sh Rd Wappingers Falls, NY 12590
CITY"OWN STATE ~p
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 D RELIGIOUS
9 D OTHER, SPECIFY
COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~c; 1368 .
~~~~;~R 112
1. A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) .
D. SOCIAL SECURITY NUMBER 068-72-2267
2. RESIDENCE A. NY B. nlltr.hp.!=:!=:
(STATE) (COUNTY)
C. CHECK ONE D CITY &il' TOWN D VILLAGE
~~~CIFY FF.lst Fishkill
D. STREET ADDRESS 30 Sarah Lane ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? DYES I!'f NO
10 / 04 / 19R?
MONTH DAY YEAR
3. A. AGE 24
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Delivery
B. TYPE OF INDUSTRY OR BUSINESS Furniture Company
5. PLACE OF BIRTH Bronxville NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME GerF.lrd CF.lrey
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Rita Moore
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE-- .-. .. .----ClVlL -ANNULMENT
o 0
DEATH
o
B. HOW 010 LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) D DEATH
(3) D ANNULMENT
/ /
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
W
UJ
Z
W
o
::i
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-t-I MAI~ 'Wfrtfd~
SIGNATURE~
DOH-98 (03/2006)
I
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
LF.lurF.l I ~nn Splain
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE CF.lrey
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 093-72-5250
12. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 30 Sarah Lane ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? DYES 1'!1 NO
/04 /1'984
DAY YEAR
13. A. AGE ?3
03
MONTH
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Graphic Designer
B. TYPE OF INDUSTRY OR BUSINESS Advertisinq
15. PLACE OF BIRTH Poughkeepsie, NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Francis John Splain
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Deborah Marqaret Farley
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
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
TIME
MONTH
YEAR
MONTH
YEAR
AM
06:45pM
11
04 2007
09
06
2007
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN;;-J(\J,. Tc.Jh1
C.
D CITY OF TOWN OF D VILLAGE OF
SPECIFY L4J ~ ~ t.. Y'L....
/1/0_-'" '7
SIGNATURE~