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COUNIY Dutchess
CITYfTOWN Wappinger
~~~~~: 1368 '
~~~~~~R 61
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Edward Frantis Brown. JR.
MIDDLE -,' CURRENT SURNAME
I""
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
1. A. FULL NAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christine Ann Withers
FIRST MIDDLE CURREN:r SURNAME
B. BIRTH NAME (MAlDEN NAME). IF DIFFERENT Pastore
C. SURNAME AFTER MARRIAGE Brown
(OPTIONAL - SEE REVERSE) 074 58 6176
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNlY)
C, CHECK ONE 0 CITY c:Y TOWN 0 VILLAGE
~~~CIFY PouQhkeepsie
D. STREET ADDRESS 621 Sheafe Road #134 ZIP 12601
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES r:1 NO
08 /10 /1963
MONTH DAY YEAR
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 121-42-8808
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNlY)
C. CHECK ONE 0 CITY [!" TOWN 0 VILLAGE
~~CIFY Pouahkeepsie
D. STREET ADORESS 621 Sheafe Road #134
ZIP 12601
E. IS RESIDENCE WITHIN UMrTS OF CITY OR INCORPORATED VIlLAGE? 0 YES rf NO
02 / 12 / 195
MONTH DAY YEAR
13. A. AGE 43
3. A. AGE 55
3B. DATE OF BiRTH
3B. DATE 9F BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Laborer
B. TYPE OF INDUSTRY OR BUSINESS Arrowhead Fencing
5. PLACE OF BIRTH Bronx, New York
(CITY. STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Peekskill, New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Anthonv Pastore
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Louise Bassi
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
6. FATHER
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LL.
<C
A. NAME Edward Francis Brown
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Teresa Durkin
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
rr.'
w
19. ~~~~Is>~{RMtFR~K'~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
~
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) D DEATH B. HOW 010 lAST MARRIAGE END? (3) D DIVORCE (3) 0 ANNULMENT jgl.Q.DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 03 / 25 / 1 ~~ts
MONTH DAY YEAR MONTH ~ DAY.'- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO . D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITYICOUNlY. STATEICOUNTRY. IF NOT USA) SELF SPOUSE (MONTH....DAY. YEARJ... (CITYICOUNlY, STATEICOUNTRY. IF NOT USA) SELF SPOUSE
1ST 0 D 1ST 03/.::::5/199ts Clifton, New Jersey D~ 0
2ND 0 D 2ND 0 0
3RD 0 D 3RD 0 0
4TH 0 D 4TH 0 0
I dul swear/affirm. dep'0S8 and say, that to the best of my knowledge and belief that the Information I provided is true eclare that no legal z.m ediment exists
as to my right to enter Into the ma ge sta e.
21. SIGNATURE OF GROOM. . F BRIDE.
USE CURRENT NAME
DATE 06/25/2007
by New York Domestic
DEATH
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DEyt
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23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New 'York State of the bride nd groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonie6 within New York State. THI LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the urpose of a second or SUbsequent ceremony.
: ,-I'-.. 24. TOWN OR CITY pL~RK C . 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn . Masterson
{SEAL SIGNATURE ~ C1a:= c ~ DATE 06/25/200 YEAR
'-.,..; ~eb&;h Rd, 11V-;;~;oger Falls, NY 12590 2007
STREET ClTYrrOWN STATE ZIP
~~~:RT~~ 'o~~~N:.zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ./
SONS NAMED ABOVE ON THE I EM. AY YEA 0 0 RELIGIOUS 1 ~IVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER. SPECIFY
MONTH
YEAR
08
24 2007
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou::;J;2,^'"R.~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY WAfPP I ~ ~ ~
SIGNATURE ~
DoH-98 (0312006)
'b
ZIP
31'WITNESST~OEM Y A~-
NAME(PRINT) _~./ rt?- _~
SIGNATURE~ o....-~.