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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
8riltlr Patrick El!ME
COUNTvO, dr.hp.~~
CITY fTOWNW8ppingp.r
~~J~~CRT1368
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1. A. FULL NAME
CURRENT SURNAME
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE,\.
D. SOCIAL SECURITY NUMBER u63-66- 3021
2 RESIDENCE AN~AXprk B. .om~mrss
C. CHECK ONE 0 CITY.,.[] TOWN 0 VILLAGE
~~~CIFY East Fi~hknl
D. STREET ADDRESs43 ~yIv8n Drive ZIP 12533
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"'tJ NO
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3 A. AGE28
4. EMPLOYMENT
A. USUAL OCCUPATION Elechir.i8n
B. TYPE OF INDUSTRY OR BUSINEssBurke Electric
5. PLACE OF BIRT~~~~~~E1C~= IX~Trtc'SAI
6. FATHER
A. NAME Rene P. BHH~
8 COUNTRY OF BIRTH Np.therlands
38 DATE OF BIRTH
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7. MOTHER
A. MAIDEN NAME Patricia Ann Ormsby
8 COUNTRY OF BIRTH l J ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
8 HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C DATE LAST MARRIAGE ENDED? / /
(2) 0 DEATH
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)
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L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
11 A FULL NAME Rp.inH C:hri~tinH RHrrp.tt
FIRST MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE B8rrP.tt - RHH~
(OPTIONAL. SEE REVERSE},.
D. SOCIAL SECURITY NUMBER I1Q~ 77-nRRfl
12. RESIDENCE .(\IP.W V nrk BDutchess
~TATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFEast Fishkill
D. STREET ADDRES43 Sylvan Drive
ZIP12533
o YES'tJ NO
1918
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGF26 13.B. DATE OF BIRTH 11 26
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCuPATlorRegistered Nurse
B. TYPE OF INDUSTRY OR BUSINESSWestchester Med. Cntr.
15. PLACE OF BIRTt-EouohkeeosieL New York
(CrT~STATE/COtJNTRY IF NOT USA)
16. FATHER
A. NAMEEatrick Allen Barrett
B. COUNTRY OF BIRTtU S A
17. MOTHER
A. MAIDEN NAME~\J~Hn Rp.ins Oonp.y
B. COUNTRY OF BIRTtU S A
1B. 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
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1ST
2ND
3RD
4TH
I, being duly SWDrn, depose and say, that to
as to my right to enter into the marriage
21. SIGNATURE OF GROOM ~
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22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 to perform marriage ceremonies within 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE 09/28/2005
r Fa Is NY 12590
/TOWN STATE
27. TYPE OF CEREMONY
0)& RELIGIOUS
9 0 OTHER, SPECIFY
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NAME (PRINT)
SIGNATURE ~
MAILING APDRE
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STREET
30. WITNESS TO CEREMONY
~"' (""~ Po
SIGNATURE 'c::;:::i2.
DOH-98 (11/98)
BAAS
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DATE 09/28/2005
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
6:21
AM
PM
09
29
2005
11
27 2005
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTyL~c:.k.<>
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 15- TOWN OF 0 VILLAGE OF
SPECIFY ~~ ~'S\..- t.-:\\
ZIP
31. WITNESS TO CEREMONY
SIGNATURE