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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Erik Randolph Ber~
MIDDLE CURRE T SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c~ 1368
~~~I:;~R 138
1. A. FULL NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
I
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C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 109-72-0980
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 35 Liss Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 29 3B, DATE OF BIRTH 04 /
ZIP 12590
dYES 0 NO
15 / 1977
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Brandy Lee McKenna
MIDDLE CURRENT SURNAME
~
DAY
YEAR
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE BerQ
(OPTIONAL - SEE REVERSE) 052-62-4954
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE)..J (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
~~~CIFY East Fishkill
o STREET ADDRESS 19 Railroad Avenue ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d' NO
10 /06 /f977
MONTH DAY YEAR
13. A. AGE 29
38. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Carpenter
8. TYPE OF INDUSTRY OR BUSINESS Union Local 19
5. PLACE OF BIRTH Beacon, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Randolph Felix Berg
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patricia Ann Eagan
B. COUNTRY OF BIRTH USA
1
B, NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEAlt
14. EMPLOYMENT
A. USUAL OCCUPATION Customer Service Manager
B. TYPE OF INDUSTRY OR BI,JSINESS Bottini 011 Co.
15. PLACE OF BIRTH PoughKeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Ronald James McKenna, Sr.
'B. COUNTRY OF BIRTH USA
17. MOTHER
A, MAIDEN NAME Rosemary Zammiello
B. COUNTRY OF BIRTH USA
1
1B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
DE'()H
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
1ST 0 0
2ND 0 0
3RD 0 0
~ 0 0
at the information I provided is true and that I declare that no legal impediment exists
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USE CUR NT NAM
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 and groom named above by any person authorized
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 CITYJCl.,ERK C M t 25 A SOLEMNIZATION PERIOD BEGINS
onn . as erson . .
NAME (PRINT)
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
o
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{ SEAL }
'-v-I
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
08/30/200
DATE
appinger Falls, NY 12590
AM
04:31pM
08
31
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
.3:00~ "-\
STATE
27. TYPE OF CEREMONY
o WRELIGIOUS
9 0 OTHER. SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY i)~..:;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF B"TOWN OF 0 VILLAGE OF
SPECIFY &T ~'S'kb II
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
9
0'"
NAME (PRINT)
SIGNATURE~
2006
10
29 2006
ZIP
~"'i'~ ;r
dOOCn
NAME (PRINT)
SIGNATURE~
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