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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 JSo~LQ Emil Sin~~~[NTSURNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~~ 1368 .
~~~I:J~R 29
SUPPLEMENTAL FILE
FROM THE BRIDE
Deborah JOY Brooker
MIDDLE CURRENT SURNAME
~
Lo
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c.. SURNAME AFTER MARRIAGE Singler
(OPTIONAL - SEE REVERSE) 056-66-3383
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY iY TOWN 0 VILLAGE
~~CIFY Wappinoer
D. STREET ADDRESS 10 Card Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r1 NO
13. A. AGE 41 3B. DATE OF BIRTH 03 / 02 /1966
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Ophthalmolooy Assistant
B. TYPE OF INDUSTRY OR BUSINES~ Medioal
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Russell James Brooker
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Sandra Joy Sedore
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL AIiNOLMENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 084 38 0558
D. SOCIAL SECURITY NUMBER --
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY iY TOWN 0 VILLAGE
AND L
SPECIFY agrange
o STREET ADDRESS 55 Scenic Hills Drive
12603
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rf NO
3. A. AGE 59 3B. DATE OF BiRTH 01 / 29 / 194
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Civil Servant
B. TYPE OF INDUSTRY OR BUSINESS Federal Government
5. PLACE OF BIRTH Manhattan. New York
(CfTY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME John E. Singler
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mildred Hilbrino
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF:lIAGE 2
9. ~~~~~~IR~FR~~'"E<vr8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
1
(2) O~EATH
2002 .
YEAR
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 08/ 29 /
MONTH .DJ.Y
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES o'lllo
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CfTYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 0 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
edge and belief that the information I provided is tru! ~nd that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE~ 12f.f2(J1~ 0 .& ()~
Ii> US~RENT NAME
DATE 04/26/2007
1ST
2ND
3RD
4TH
I duly swear/affirm, deP.Ose and say I that to the best
as to my right to enter into the ma stat,?
21. SIGNATURE OF GROOM~ V
23. SUBSCRIBED AND SWORN T FARMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the 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.
o 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
} NAME (PRINT) J C. Ma
{ C TIME MONTH DAY YEAR MONTH
SEAL SIGNATURE ~' DATE 04/26/200
'-v-I MAIL~~~rda1e sh Rd, Wappinger Falls, NY 12590 01 :4~~ 04 27 2007 06 25 2007
STREET CfTYlTOWN STATE ZIP
~~~R~~R~~~ IO~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27~F CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR O~RELlGIOUS 10 CIVIL
DATE AND AT THE TIME AND A
PLACE INDICATED.~ I "2~~O P r (p ~ 0 I 9 0 OTHER, SPECIFY
1!'~,f'(::1.'::lr _ . r {j ~p C lIoa Ie mu
SIGNATURE~ ~ a U _t7~Cl0 DATE
MAILING ADDRE~ /J:. i /'. / I r
12- 5q n'l!"Y. €' €..- /"" . yv4 "(:'" f rq( rJ
STREET CITYfTO N
30. WITNESS TO CEREMONY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D It fr:j,~ sS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF t/ VILLAGE OF
SPECIFY W'OjJI I,j ~ t'i/C f ~! I.J
f1 /
