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c'TYrrowNWappinger
~~~~~~, 368
~~~I~~~ry 4
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
StF'!rh~I~Dl~nthnny 9:!fR~~URNAME
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Reb~I~~r Lynn Fry~RENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGERir.hey
(OPTIONAL - SEE REVERSEij.
D. SOCIAL SECURITY NUMBER u89-76-7899
12 RESIDENCE .Ny Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 ClnYb TOWN 0 VILLAGE
~~~cl~oughkeepsie
D. STREET ADDRES~ 6 Aida Drive
ZI~ 2603
o YE~'o NO
1.983
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE..l
D. SOCIAL SECURITY NUMBER I 08-70-7144
2. RESIDENCE ANY B. nlltr.he!=:!=:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 Tow""D VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRES~2 Franklindale Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
/?1 /1977
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~3 3B. DATE OF BIRTH 12 11
MONTH DAY
3. A. AGI09
11
MONTH
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Letter Carrier
B. TYPE OF INDUSTRY OR BUSINESSU. S. Post Office
5. PLACE OF BIRT~old Spring. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Franklin Francis Richey
B. COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME Brenda Sue Carney
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 IT
14. EMPLOYMENT
A. . USUAL OCCuPATlorSales Manager
B. TYPE OF INDUSTRY OR BUSINES&Glaire's
15. PLACE OF BIRTtP-ouQhkeepsie, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEOouglas Jay Frye
'B. COUNTRY OF BIRTkJ S A
17. MOTHER
A. MAIDEN NAM~andra Ann Silvestri
B. COUNTRY OF BIRTW 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
~
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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. 4F .PflEVlQlJSLY DIVORCED 0R 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
2ND
3RD
4TH
I duly swear/affirm, depose and
as to my right to enter into the
21. SIGNATURE OF GROOM~
o 1ST 0 0
o ~D 0 D
o 3RD 0 0
o 4TH 0 0
nd belief that the information I provided is true and that I declare that no legal impediment exists
SIGNATUR OF BRIDE~ --{J ^ inn......rA 7~..(
~ECURReNTNAME
DATE /25/2007
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by New York Domestic
23. SUBSCRIBED AND SWORN TO/AFFIRMED B
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the
Relations Law ~11 to perform marriagB ceremonies within New York Sta
o If checked, this license is to be used onl
t-'-.. 24. TOWN OR CITY LER~
} NAME (PRINT) JO L;. Mast r on
{SEAL SIGNATURE ~ DATE 07/25/2007
'-v-' M~~~~f~ appinger Falls, NY 12590
STREET ClTYrrOWN STATE ZIP
~~~R~:Ri~~~ IO~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 00 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
ride d groom named above by any person authorized
THIS LICENSE VALID IN NEW YORK STATE ONLY,
for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
fMA~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF rs/TOWN OF 0 VILLAGE OF
SPECIFY \tJ':.r. ~~'\
SIGNATURE ~