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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1. A. FULL NAME ~~ Andrew Bf!II
~ MIDDLE
DATE 1011112005
of the bride and groom named above by any person authorized by New York Domestic
w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ } NAME (PRINT) .. TIME
SEAL SIGNATURE ~ DATE 1Of11/2005
'-y-I M~Uf&i6bush Rd, Wappinger Falls. NY 12590 11:39
STREET CITYITOWN STATE ZIP
~~~R~~~Ri~~~ IO~O~~~NifEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED.
TITLE ...:r u.J!. 'T1 c:...
'TIC (oj$/I'Z.DD5"
~_IJ~ J
STATE ZIP
31. WITNESS TO CEREMON
COUNTY Dutch-
CITYfTOWN Wappinger
~~~~ifRT 1368
~5~I~J~R 1 ~
CURRENT SURNAME
0-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)Oi1~ nft ~5
D. SOCIAL SECURITY NUMBER --~~-
2. RESIDENCEA. ~Tlork B. ~.
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \A...........
SPECIFY .. ..lIIBAIInpeI'
D. STREET ADDRESS 12 Clndv Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE? 0 YES ~ NO
3. A. AGE n 3B. DATE OF BIRTH ()g /20 / j QZ2
MONTH DAY y"(lR
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4. EMPLOYMENT
A. USUAL OCCUPATION MUBici8n
B. TYPE OF INDUSTRY OR BUSINESS Quest 1 Mgt.
5. PLACE OF BIRTH Manchester. EN'IIsnd
(CITY, STATE/COUNTRY IF~USA)
6. FATHER
A. NAME Jaseph Bell
B. COUNTRY OF BIRTH Ireland
7. MOTHER
A. MAIDEN NAME MAry M~AAI'
8. COUNTRY OF BIRTH Ireland
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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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
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STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME T~ Lee p~
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~\~M~~~~:~~e~~~1
D. SOCIAL SECURITY NUMBER ~-EV-5224
12. RESIDENCE A.~ Vork' B. nllt~
~A"'I'E) ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND 'AI- .
SPECIFY VVIIPPa,ger
D. STREET ADDRESS 12 Clncty Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES.tJ NO
13. A. AGE31 13.B. DATE OF BIRTH M .(3 1s7A
--'NTH DAY ~
14. EMPLOYMENT
A. USUAL OCCUPATION Hair styIiBt
B. TYPE OF INDUSTRY OR BUSINESS C8rt1~ SAlon
15. PLACE OF BIRTH~~~~N~ York
16. FATHER
A. NAME~ Geor.ge Pnwel1l
B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Carmen ~d. Colon
B. COUNTRY OF BIRTt-PueJfft ~CO
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
o
o
o
o
o
o
o
o
o
o
o
S
MONTH
YEAR
MONTH
YEAR
AM 10
PM
12
2005
12
10 2005
CIVIL
2B. PLACE WHERE MARRIAGE OCCU~
A. STATE NEW YORK B. COUN~~
C. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY
~t.hJM..
NAME (PRINT)
SIGNATURE ~