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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher John Donnelly
FIRST MIDDLE
D D 1ST D D
D D 2ND D D
D D 3RD D D
D D 4TH D D
knowl dge and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ ~ O.~
( USE CURRENT NAME 04/26/2006
DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
Jo n C. Mast
C.
ush Rd
COUNTvOutchess
CITYfTOwNWappinger
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1. A FULL NAME
CURRENT SURNAME
0:.1"'1:. riLE: NUMttCt1
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE087 60-7946
o SOCIAL SECURITY NUMBER -
2. RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY 'tJ TOWN D VILLAGE
ANDp hk .
SPECIFY OUQ eepsle
o STREET ADDRESS 567 Sheafe Road, #31 ZIP 1259IJ
.;
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES D NO
3 A. AGE:\:\ 3B. DATE OF BIRTH 08 /16 /1972
MONTH DAY YEAR
11. A.
FROM THE BRIDE
FULL NAME Carrie Ann Smith
FIRST MIDDLE
CURRENT SURNAME
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4. EMPLOYMENT
A USUAL OCCUPATION Chemical Technician
B. TYPE OF INDUSTRY OR BUSINESS Schott Lithotec
5. PLACE OF BIRTHRhinebeck, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME James H. Donnelly
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Doris Mae Place
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DE~ TH
B. BIRTH NAME (MAIDEN NAME), IF DIFFEREN~
C. SURNAME AFTER MARRIAGE Donne IY
(OPTIONAL - SEE REVERSE051-66-7933
D. SOCIAL SECURITY NUMBER
12. RESIDENCE AN Y B Dutchess
(STATE) '" (COUNTY)
C. CHECK O"W: Q CITY D TOWN D VILLAGE
~~~CIFYJJOugtiKeepSle
567 Sheafe Road, #31
D. STREET ADDRESS
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B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D 1~J;l NO
13. A. AGE24 13.B. DATE OF BIRTH 06 ?/l ~
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
\1. V. Otolaryngology
B. TYPE OF INDl.j~TRY oa BUSI"jIijlS Y rk
15. PLACE OF BIRTHl\.lngs on, ew 0
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Randy Scott Smith
B. COUNTRY OF BIRTHU 5 A
17. MOTHER
A. MAIDEN NAME Deborah Ann Brooks
B. COUNTRY OF BIRTHU S ~
lB. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DltfRCE CIVIL A"fiULMENT
D'OTH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and
as to my right to enter into the
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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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21. SIGNATURE OF GROOM ~
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{ } NAME (PRINT)
SEAL SIGNATURE ~
'-..,-I MA~51OO~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
AM 04
05:43 PM
27
2006
06
25 2006
2B. PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
A. STATE NEW YORK B. COUNTY \H..."'e...
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF \iiJ TOWN OF D VILLAGE OF
SPECIFY Q ~ \ ~ \.. r - vJ p Wt)-t.)'~
ITLE C\e C"')'j
ATE 2."'1 N\<>.; ~Oc>\'"
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31.
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SIGNATURE ~