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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bnm Francis IMnY
COUNTYD. dchess
CITYITOwNWapplnger
~~J:~~T1368
~5~~J~R41
1. A. FULL NAME
CURRENT SURNAME
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8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEJ.-.
o SOCIAL SECURITY NUMBER w()..7D-7278
2. RESIDENCE AN.Xp:k 8. D~8
C. ~~6CK ONE 0 CITY.rJ TOWN 0 VILLAGE
SPECIFY PI~1lt Valley
D. STREET ADDRES1i?1n Lekesbore DrIve ZIP 12569
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 Y~ NO
3. A. AGQ.7 3B. DATE OF BIRTH nL k.... ~ 0':20
IlIrnfTH ' ~AY , loiMAlil7
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4. EMPLOYMENT
A. USUAL OCCUPATION Graphic Designer
B. TYPE OF INDUSTRY OR BUSINES<SeIf Employed
5. PLACE OF BIRnP~r;'~FMM;Y'ork
6. FATHER
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A. NAMEGeorge David Barry, Jr.
B. COUNTRY OF BIRTfll S A
7. MOTHER
A. MAIDEN NAME Mary AnA DeGreodt
B. COUNTRY OF BIRTHU S A
B. NUMBER OF THIS MARRIAGE1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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(2) 0 DEATH
DEATH
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A.
FUU NAMEJesU CoIek s.-man
CURRENT SURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGEO-m .
(OPTIONAL - SEE REVER!M!!3 7
D. SOCIAL SECURITY NUMBER 103--7-Q..9158
12. RESIDENCE -Nel.1T)fQFk BD~
C. ~~6CK ONE 0 CITY.jJ TOWN 0 VILLAGE
SPECIFt..4Jappinger
D. STREET ADDRE529G Alpine OFiYe ZI,2590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE? 0 YE~ NO
13. A. AG~" 13.B. DATE OF BIRTH n.t .L 12ft
" U.ONTH ff DAY STaEAR
14. EMPLOYMENT
A. USUAL OCCUPATI01Ret8i1 Manager
B. TYPE OF INDUSTRY OR BUSINES11 & M
15. PLACE OF BIRT~I'FNewAifork
16. FATHER
A. NAMCaFl Thomas 8&ss&man
B. COUNTRY OF BIR" S A
17. MOTHER
A. MAIDEN NAMSuzanne Colette Ricard
B. COUNTRY OF BIR~ G A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
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(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
o
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~ DAT
This license authorizes the marriage in New York person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit New YDrk 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
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TIME
MONTH
NAME (PRINT
SIGNATURE ~
MAILING ADDRESS
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
MONTH
YEAR
if 01 2006
2B. PLACE WHERE MARRIAGE OCCURRED
03
2006
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR 0 ~ RELIGIOUS
AM
3: OO"M 5 20 '06 90 OTHER, SPECIFY
10 CIVil
A. STATE NEW YORK B. COUNTY Dutchess
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY Poughkeepsie
29. OFFICIANT R J h P LaM
""" I""",~ . orte
SIGNATURE ~ ~
MAILING ADDRE
775 Main Street Poughkeepsie
STREET CITYITOWN
30. WITNESS TO CEREMONY
DATE
TITLE Catholic PrieRt
M;lY 20. 2006
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NY
STATE
1260
ZIP
31. WITNESS TO CEREMONY
/'
NAME (PRINT)
SIGNATURE ~