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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Anrl~l~b'ti Peter M~U~~QfRNAME
USE CURR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of t authorized by New York Domestic
Relations Law ~11to perform marriage ceremonies within New York te. 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) Joh C. Master
C
COUNTY Dutchess
CITYfTOWN Wappin~er
~~~=~c: 1368 .
~5~~~~R 182
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 080-66-6427
D. SOCIALSECURITYNUMBER ___ -_ - -
2 RESIDENCE A. NAW York B. DIJtchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 510 Malonev Road 0-4 ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES c( NO
3. A. AGE ?R 3B. DATE OF BiRTH n~ / 1 n / 1 ~7
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Bus Driver
B. TYPE OF INDUSTRY OR BUSINESS N. Y. C. Transit
5. PLACE OF BIRTH Carmel. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Willi;:Jm F Me G;:Jrry
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Kathleen R. Smith
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
n 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
1D. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
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r-A-.
{ SEAL }
'-v-'
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Stacy Christine Brinsfield
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Brinsfield
(OPTIONAL. SEE REVERSE) 052 72 81 07
D. SOCIAL SECURITY NUMBER --
12 RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cY TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 34 Hi View Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES cf NO
08 /13 /1986
MONTH DAY YEAR
13. A. AGE 20
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME William Hudson Brinsfield, Jr.
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nancy Jayne Groton
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) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
"- YEAR
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
1ST
2ND
3RD
4TH
o
o
o
o
o
o
o
o
TIME
MONTH
YEAR
MONTH
YEAR
SIGNATURE ~
MAILING ADDRESS
20 Middleb
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 12/06/200
h Rd. Wap"oinaer Falls, NY 12590
CITYITO\YN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 0 RELIGIOUS
~ ~M 9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
10:2')1\M
PM
12
07
2006
02
04 2007
~IL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK B.COUN~~\"(S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECI~..l.J o...'W)'1J,. Ore ,--