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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST JotaaKrednc G~~UAfWIE
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Outchess
ClTYfTOWN Wappinger
~~a:oc: 1368
~~~~~R 76
Lo
--1
SUPPLEMENTAL FILE
FROM THE .BRIDE
Je~ Lynn 5QMiflt SURNAME
11. A. FULL NAME
FIRST
..
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE GreeRFN'
(OPTlONAL - SEE REVERSE) ~
D. SOCIAL SECURITY NUMBER nRQ.. 7'-Rn~ 1
12. RESIDENCE A. NIWrl one B. ~els
C. CHECK ONE 0 CITY Do'" TOWN 0 VILLAGE
AND W .
SPECIFY "pplnger
D.STREET ADDRESS 109 Popula Boulevard 2IP. 12590
E. IS RESIDENCE WIlHIN UMITS OF CITY OR INCORPORATED VlUAGE'I 0 YES r!f NO
13. A. AGE 24 38. DATE OF BIRTH ~ / ~ -1~
14. EMPLOYMENT
A. USUAL OCCUPATION Photo Technician
B. TYPE OF INDUSTRY OR BUSINESS L- V ~
15. PLACE OF BIRTH PnIJnhkfl.en!eie New Vnrk
(CITY, STihE I i:Xiiifi'RY IF 1iiT USA)
16. FATHER
A. NAME Malt S Squier:
B. COUNTRY OF BIRTH l' J ~ A
17. MOTHER
A. MAIDEN NAME VAIp.rip. I TrAVp.r
B. COUNTRY OF BIRTH I J !:;; A
1B. NUMBER OF THIS MARRIAGE 1
19. ~~~fmr8Jr8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 176-R'-~7n4
2. RESIDENCEA.~_)YOrt B. ~.sr
C. CHECK ONE 0 CITY [iI.I' TOWN 0 VILLAGE
AND 'A' .
SPECIFY \JlfSpplnger:
D. STREET ADDRESS 1 nR PQPUIA BoulevArd ZIP 12590
E. IS RESIDENCE WIlHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES r!! NO
3. A. AGE 26 3B. DATE OF BIRTH ~ / Jr5 / 379
4. EMPLOYMENT
A. USUAL OCCUPATION Netwolt Technicisn
B. TYPE OF INDUSTRY OR BUSINESS Mt ~t MAry L-ollp.gp.
5. PLACE OF BIRTH N~'lrn'" New Vnrk
(CITY, STATE I Ci3'UiiffRy IF NOT USA)
6. FATHER
A. NAME William Joseph GreeRey
B. COUNTRY OF BIRTH II ~ A
7. MOTHER
A. MAIDEN NAME Diafle RAgdftnA~
B. COUNTRY OF BIRTH II ~ A
B. NUMBER OF THIS MARRIAGE 1
9. ~~W~~~~~us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
(2) 0 DEATH
(3
DEATH
n
DEATH
n
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) (CITYICOUNTY. STATEICOUNTRY. IF NOT USA) SELF SPOUSE
YEAR
1ST 0 0 0 0
2ND 0 0 0 0
3RD 0 0 0 0
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by New York Domestic
of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
TIME
MONTH
YEAR MONTH
YEAR
flR/1 Q/7nn
11 :02'M
PM
06 20 2006 08 18 2006
STR ET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A
27. TYPE OF CEREMONY
O)l(REUGIOUS
9 0 OTHER, SPECIFY
p
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~ l4.I:z,L.....
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
::OFX:;tk~OF
1 0 CIVIL
29. OFFICIANT
NAME (PRINT)
T1T1.E -P I)...$-+>>r
::r '" No(. 2.&i \ ~., ~
Ai "z..c ~ i'
NAME (PRINT)
SIGNATURE~
DOH-9B (07/2005)
NAME (PRINT)
SIGNATURE~