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STATE OF NEW YORK
DEPARTMENT OF HEALTH
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JltImn Gregorvll~r.phy, JRCURRENT SURNAME
COUNTY 01 tfr.:hp.~~
CITYrrOWN WRppinger
~~~:~; 1 ~RR
~~~I~~~R Rfi
1. A. FULL NAME
ll.
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 129-4.R- 71 fi 1
2. RESIDENCE A. NiftWrEY ork B. ~e!s
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applJ:tger
D STREET ADDRESS ~, O~home Hill Rd
Apt. 5 ZJP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES t1 NO
MO~ / g~ / yl~67
3. A. AGE 38
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Hyde Part Cntrl. Shl. Oist.
5. PLACE OF BIRTH ()up.p.n!i: Np.w Y ort
(CITY, STATE / dOUNTRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
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A. NAME Justin Gregory Murphy
B. COUNlTRY OF BIRTH ~ J ~ A
7. MOTHER
A. MAIDEN NAME Arlp.np. ~itRrp.lla
8. COUNlTRY OF BIRTH I ) ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENIT
o n
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEAlH
C. DATE LAST MARRIAGE ENDED?
YEAR
MONni OAY
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
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Kern Ann Eissin~
RRST MI OLE
~
CURRENT SURNAME
B. BIRTH NAME (MAlDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE MurphY
(OPTIONAL - SEE REVERSE) 112 72 0725
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New Y ort B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r1 TOWN 0 VILLAGE
~~~CIFY Waooinaer
D. STREET ADDRESS 52 Osborne Hill Rd. Apt. 5
ZJP 12~HU
~
o YES 0 NO
'UJ79
YEAR
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE '7 38. DATE OF BIRTH 03 Al3
MaNni OAY
14. EMPLOYMENT
A. USUAL OCCUPATION Social Worter
B. TYPE OF INDUSTRY OR BUSINESS Orange Reg. Med. Cntr.
15. PLACE OF BIRTH Port Jervis, New Yort
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Kenneth Henry Eissinq
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Kathleen Elizabeth Hanrahan
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVDRCE CIVIL ANNULMENIT
o 0
DT
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEAlH
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH OAY
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
(MONITH, DAY, YEAR) (CITY/COUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say
as to my right to enter into the m
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ge and belief Ihat the infonnation I provided is true an
o 0
o 0
o 0
o 0
are that no legal impediment exists
USECU E N
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of Ihe bride and groom named above by any person aulhorized
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 Ihe purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE 06/05/200
in er Fa s NY 12590
ClTYrrOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 ~EUGIOUS
, . dD :- 0" t.4 0" 9 0 OTHER, SPECIFY
~
{ SEAL }
'-v-I
NAME (PRINT)
STREET
J CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMEO ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
w
.-
<( 29. OFFICIANT
(,) NAME (PRINT)
LL
SIGNATURE~
i= MAILING ADDRESS
Wa: 'r~ F,A.y( AVE" fJE("MA'M
STREET CITYrrOWN
(,) ~:~~~~:~T.ocr<;f;~'V\~"--Ei~~I~~
06/05/2006
by New York Domestic
TIME
YEAR
MONTH
YEAR
MONlTH
AM
12:5]PM
06
06
2006
08
04 2006
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 2)c.rrCk~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY OF 0 TOWN OF 0 VILLAGE OF
TIf,C'n1t
(~ M.~
,uv.
DATE ~ .2.~"" 2.4\71
Ny 10 to .s
STATE
llE"uw
NI""'O U.S
TlTLIE
SJGNATURE~
DOH-98 (07/2005)
SPECIFY