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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brendan Caulfield - James
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN WappinQer
~~~~~c: 1368 .
~5~1;~~R 96
1 . A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE)
C. CHECK ONE 0 CITY 0
~~~CIFY Fishkill
D. STREET ADDRESS 56 Shirley Avenue ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r$ YES 0 NO
3. A. AGE 72 3B. DATE OF BIRTH 02 / 05 / 1934
MONTH DAY YEAR
B Dutchess
(COUNTY)
TOWN 1!1' VILLAGE
t-
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II(
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J:lu.
II(
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Retired
5. PLACE OF BIRTH SinQapore
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Frank Caulfield - James
B. COUNTRY OF BIRTH Thailand
7. MOTHER
A. MAIDEN NAME Iris Ess
B. COUNTRY OF BIRTH Thailand
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
000
~
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
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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
Nor
us ~ 1)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mary Marqaret Brockwav
FIRST MIDDLE CURRENT SURNAME
B. 81RTH NAME (MAIDEN NAME), IF DIFFERENT Mylod
C. SURNAME AFTER MARRIAGE Mylod
(OPTIONAL - SEE REVERSE) 122-28-5483
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN r5 VILLAGE
~~~CIFY Fishkill
D STREET ADDRESS 56 Shirley Avenue ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 1'1 YES 0 NO
05 /08 /1'935
MONTH DAY YEAR
11. A. FULLNAME
13. A. AGE 71
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Painter
B. TYPE OF INDUSTRY OR BUSINESS Self-employed
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Frank Mylod
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Elizabeth Beck
B. COUNTRY OF BIRTH USA
2
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DE.A,TH
001
~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT ~~ DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 23 / 19
MONTH ,JJA Y - 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
",'
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that 0 the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the mar tate, i
21. SIGNATURE OF GROOM'-
23. SUBSCRIBED AND SWORN TO/AFFI
SIGNATURE OF TOWN OR CITY CL
CITY (TOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
AM
PM
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
DOH-98 (03/20D6)
CITYfTOWN
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~