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COWrY Dutchess
CITYrrOWN Wappinger
~~~:~cFi 1368 .
~~~~J~R 1 09
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel Lee Brunell
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Jacqueline Lorene Almond
MIDDLE CURRENT SURNAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Brunell
(OPTIONAL. SEE REVERSE) 064-68-9902
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STA~ (COUNTY)
c. CHECK ONE CITY 0 TOWN 0 VILLAGE
AND P k .
SPECIFY oug eepsle
D. STREET ADDRESS 421 Baker Street; Apt #1 ZIP 1 ~OU;:S
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? r5 YES 0 NO
10 /02 /1981
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 125-66-1398
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATj) (COUNTY)
c. CHECK ONE I!I CITY 0 TOWN 0 VILLAGE
~~~CIFY pou~hkeepsie
D STREET ADDRESS 21 Baker Street; Apt #1 ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? dYES 0 NO
04 / 21 / 1981
MONTH DAY YEAR
13. A. AGE 24
3. A. AGE 25
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS Electric
5. PLACE OF BIRTH Brooklyn, New York
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUf:\IRY pR ~,sINES& . Pre-school
15. PLACE OF BIRTH railS l,;nurcn, Virginia
(CITY, STATE I COUNTRY IF NOT USA)
I eacher
6. FATHER
A. NAME Dan Brunell
B. COUNTRY OF BIRTH USA
16. FATHER
A. NAME Rex Earl Almond
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lorraine Mary Crowter
USA
B. COUNTRY OF BIRTH I
18. NUMBER OF THIS MARRIAGE
7. MOTHER
Theresa Florio
A. MAIDEN NAME
USA
B. COUNTRY OF BIRTH
~
8. NUMBER OF THIS MARF,lIAGE
DE'ff
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
DEffH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOqCE CIVIL ANN~LMENT
~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE02 (3) 0 A~ENT 1b8~EATH
C. DATE LAST MARRIAGE ENDED? ~ /
MONTH ~ DAY
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
("lQwtj..W.Y.2~ S(C11Y/COUNTY,A,TATElCffiNTFQ:,JF NOT ~~A) k SELF SPOU1
1ST UL./L.'d/; :uuo ulllvan voun y, l'Iew lor 0 0 1ST
o D 2ND
o D 3RD
o 0 4TH
81 of my knowledge and ef that the information 1 provided is t
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'.- YEAR
YEAR
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
o
o
o
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 ana groom named above y 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 CI~811~ C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
W
tn
Z r-I'-..
W
~ {SEAL}
'-..t-I
MONTH
YEAR
TIME
MONTH
YEAR
DATE
ails, NY 12590
09
06:11AM
PM
07
27
2006
STATE
27. TYPE OF CEREMONY
TIME MO. AY YEAR 0 B"'FiELIGIOUS
/./,'pO A~ ~. '" 1 2.00'(:;, 9 0 OTHER, SPECIFY
ZIP
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
1 0 CIVIL
A. STATE NEW YORK B. COUNTY OUT[ NE S5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF [3" VILLAGE OF
SPECIFY SffiATS6URh
~~~:i~~~-HI~A ~ ,~,. :::II€.S_ mLE ASSlJUI'lTE PAsmI<.
SIGNATURE~~ 'X __M.i.~ DATE AUG.b..:200(,
MAILING ADDRESS
J 4 WILLOW{;RooK. HTS. HiQ;"cps\ ~ NY 12(,03
STREET CITYrrOWN STAtE ZIP
30. WITNESS TO fjfREMONY MONY
NAME (PRINT) ~,.....()4..() NAME (PRI
SIGNATURE~ SIGNATURE