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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1. A. FULL NAME Brvan David Minhol7
l!iRST MIDDLE
COUNTY Dutchess
CITYfTOWN Wappinaer
~~J~~c~ 1368
~5~~J~R 127
CURRENT SURNAME
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) OQ..7
D. SOCIAL SECURITY NUMBER 1 ().. 7::\JlR
2. RESIDENCE A New York 8. ~!':!':
c. CHECK ONE (STAg) CITY ~ TOWN 0 VILLAGE ( U )
AND P hk .
SPECIFY oug eepsle
D. STREET ADDRESS 1112 Cherry Hill Dr. ZIP 12603
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'fJ NO
3. A AGE::\::\ 38. DATE OF BIRTH MgJH /Oly /1.:lZ2
4. EMPLOYMENT
A USUAL OCCUPATION Dispatch Manager
8. TYPE OF INDUSTRY OR BUSINESS Amoff Moving & Storage
5. PLACE OF BIRTHNorth Hempstead. New York
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Donald Edward Minholz
8. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Saundra Gail Gentile
8. 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
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STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
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DEATH
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8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A FULL NAME Ra~,~s~1 Yvonne mviamson
CURRENT SURNAME
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. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. s~~~~~(M~E~~t~~c~~Minholz
D. SOCIAL SECURITY NUMBER 12.4-72-7750
12. RESIDENCE ANe~AY,prk 8. D\f!~~s
c. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND P h'- .
SPECIFY OlJg ll:ep.p!':lp.
D STREET ADDREss1112 Cherry Hill Dr zIP1J1fin::\
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES -lJ NO
13. A. AGE31 13.8. DATE OF BIRTH 11NTH 03 DAY 1;7~AR
14. EMPLOYMENT
A USUAL OCCUPATIONC:IJ~tnJl1p.r Service Rep
B. TYPE OF INDUSTRY OR BUSINESsMarshRII .\ SIp.fling, Inr.
15. PLACE OF BIRTHLisbum.lreland
(CITY, STATe/COUNTRY IF NOT USA)
16. FATHER
A. NAME Thorn RS Hp.nry WiIliRrn~nn
B. COUNTRY OF BIRT~reland
17. MOTHER
A. MAIDEN NAME Mary Kathleen Ann Hewitt
B. COUNTRY OF BIRT~reIRnd
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
n
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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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I, being duly sworn, depose and say, that to 1he best of my knowledge and belief 1hat the information I provided.
as to my right to enter into the m . estate.
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State f the bride and groom named above by any person authorized
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
} NAME (PRINT) J~~ Maste~
{SEAL SIGNATURE ~ 'It-. () 1t).~ -=- DATE09/28f2005
'-v-' M~titt.tfdfe ush Rd, Wappinaer Falls. NY 12590 7".07 ~~
STREET Cr!'\'/TOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- ~
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR ~RELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
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DATE 09/28/'005
by New York Domestic
TIME
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YEAR
11
27 2005
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED J
A. STATE NEW YORK B. .~ -1<:. ~ s.J
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~CITY OF 0 TOWN OF 0 VILLAGE OF
,,,,,,,pc!! ~""'I' J7 ~
L-l r1'\~
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~