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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
\Nllliam Brian Saylor
FIRST MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUN~ Dutchess
CITYfTOWN ::plfingef
DISTRICT 1
NUMBER
REGISTER 153
NUMBER
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FUUL NAME Mary Thersa Beguine
FIRST MIDDLE
CURRENT SURNAME
11. A.
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Saylor
(OPTIONAL. SEE REVERSE) 075-74-5702
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECK O~F,. L IJ CITY D TOWN 0 VILLAGE
~~~CIFY vvapplnger
D. STREET ADDRESS II D pemDroke urc1e
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 22 13.B. DATE OF BIRTH 10
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Resjstered Nurse
B. TYPE OF INDU~,=!,!.~~~1I1~I\Mngate N. LJUtchess
15. PLACE OF BIRTH tlougnKeepllle, NeW York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME James Paul Beguine
B. COUNTRY OF BIRTH U ~ A
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)406-19-0613
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York . B. Dutchess
(STAT.E) J (COUNTY)
C. CHECK ONE 0 CITY J:] TOWN 0 VILLAGE
AND We .
SPECIFY pplnger
D. STREET ADDRESS 9 D pembrOke CirCle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
04 /01 /1980
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3. A. AGE 25
3B. DATE OF BIRTH
MONTH
DAY
YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION Field Service Engineer
5. :~::~~:I::Hu~or;ma~ =':~=:ogIes
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
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A. NAME Wlllam Carl Saylor
B. COUNTRY OF BIRTH U 5 A
7. MOTHER
A. MAIDEN NAME Kathy Faye Engle
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOciCE CIVIL ANa'LMENT
DEi)H
17. MOTHER
A. MAIDEN NAME Chartene Mary Barols
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'6RCE CIVIL AN&ULMENT
DE6H
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 ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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
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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o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
and belief that the information I provided is true and that I declare that no legal impediment exists
2. SIGNATURE OF BRIDE ~ ~r'....uc:k....i -<-.... <...
~RRENT NAME 1212012OO5
DATE
This license authorizes the marriage in New York 5t e of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi New York 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 _G.L:ER~ M~ 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) .JOnn v. ~
~ {' 1"1'V\1"VV\I:. TIME MONTH DAY YEAR MONTH
SEAL SIGNATURE ~ \....- -:5;:..- DATE Q~UI~\AhI
"-v-l M~ Rd, ppinger Falls, NY 12590 02 18 2006
STREET CITYITOWN STATE
~~~R~~Ri~~~ lo~O~~N~zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 00 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
21. SIGNATURE OF GROOM
23.
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YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~fI\nJfQ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF ~ILLAGE OF I":.. JJ
WAPP/~ l'7ift
NAME (PRINT)
SIGNATURE~ .
DOH-9a (11/9B)