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STAlE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROMTHE GROOM
John William Brinsfield
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~~ 1368 '
~~~I:J~R 1 04
1, A, FULL NAME
FIRST
lL
N
Be BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 124-68-2978
D, SOCIAL SECURrrY NUMBER
2. RESIDENCE A, New York B, Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!f TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 34 Hi View Road
ZIP 12590
E IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
02 / 29 / 198
MONTH DAY YEAR
3, A, AGE 22
38, DATE OF BiRTH
4, EMPLOYMENT
A USUAL OCCUPATION Student
B, TYPE OF INDUSTRY OR BUSINESS Suny Potsdam
5. PLACE OF BIRTH Poughkeepsie. New York
(CITY, STATE / COUNTRY IF NOT USA)
6, FATHER
A, NAME William H. Brinsfield
B, COUNTRY OF BIRTH USA
7, MOTHER
A, MAIDEN NAME Nancy Groton
B, COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE 1
9, ~~~~l?~~R~FR~h')R,~8us MARRIAGES WHICH ENDED BY
D1V08CE CIVIL ANN~LMENT
DEAlt
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?, DYES D NO
10, IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNmy. IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Erika Jolie Anqevine
MIDDLE CURRENT SURNAME
--1
11. A, FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Brinsfield
(OPTIONAL - SEE REVERSE) 525-55-2702
D, SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE D CITY r:f TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D, STAEETADDRESS 93 Cardinal Dnve ZIP 12601
E IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? DYES d NO
01 /31 /1984
DAY YEAR
13. A. AGE 22
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BI,JSINESS Suny Potsdam
15. PLACE OF BIRTH PoughKeepSie, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William T. A~evine
'B. COUNTRY O'F BIRTH U S
17. MOTHER
A. MAIDEN NAME Mary E. Cullen
B. COUNT~Y OF BIRTH USA
1
18, NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
DEffH
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) D ANNULMENT (2) D DEATH
/ /
. ./ YEAR
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, aeP.056 and say I that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the ma a state. .
..
21. SIGNATURE OF GROOM~ . SIGNAT E OF BRIDE~
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USE CURR
23. SUBSCRIBED AND SWORN T IRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the
Relations Law ~11 to perform marriage ceremonies within New York Sta
o If checked, this license is to be used on
24. TOWN OR CITYI I'll< C M t
'" n . as erson
NAME (PRINT)
ride and groom named above by any person authorized
THIS LICENSE VALID IN NEW YORK STATE ONLY.
for the purpose of a second or subse uent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
07/21/200 TIME MONTH YEAR MONTH DAY YEAR
DATE
appinger Falls, NY 12590 01:1~~ 07 22 2006 09 19 2006
STATE ZIP
27. TYPE OF CEREMONY
o\" o ~IGIOUS ;:11 D CIVIL ~ t:O\. A.
9 OTHER,SPECI (\~L
C.
~
{ SEAL }
'-v-'
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
07/21/2006
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
ATE
31.;WITNESS TO
N..J.4E (PRINT) .
SIG*TURE~