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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
steven R. Hart
FIRST MIDDLE
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNi-Y Dutchess
CITY"O~N Wappinger
~~J~~CRT 1368
~5~~J~R 81
L D SUPPLEMENTAL FILE
FROM THE BRIDE
11. A FULL NAME Jessica Rae Biar
FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ....rt
(OPTIONAL - SEE REVERSE) 1"'" r::~
D. SOCIAL SECURITY NUMBER 13 -1~-;xxs;J
12. RESIDENCE A. tJAAt Vark B. nlltr.hMul
~'itl ~
C. CHECK ONE 0 CITY r!!! TOWN 0 VilLAGE
AND We .
SPECIFY panger
D. STREET ADDRESS 40 0 Scal'borouph Lane
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1""" ~.. ~
D. SOCIAL SECURITY NUMBER -~
2. RESIDENCE A. NAIl Vark B. [)utM.mut
. -~tE) (~)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND We .
SPECIFY PPngel'
D. STREET ADDRESS 40 0 Scarborough Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES' ~ NO
3. A. AGE 24 3B. DATE OF BIRTH 1? /11 /1ARO
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ~ 13.B. DATE OF BIRTH OQ )(1
MONTH DAY
ZIP 12590
o YES~ NO
1IIR1
YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION Saflware Engineer
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
5. PLACE OF BIRTH Raw Share. NewVork
~ STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Roland Hart
B. COUNTRY OF BIRTH Canada
7. MOTHER
A. MAIDEN NAME Camllrw Eileen KlI'\Q
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS EllenvlUe C. S. D.
15. PLACE OF BIRTH Raw Share. New York
~, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Arthur Clinton Siar
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME BArbara .JMn \NhIte
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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o 1ST 0 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
belief that the information I provided is true and that I declare that no legal impediment exists
2 SIGNATURE OF BRIDE" 9f/YU .:u.J- 1'{. ~
USE CURRENT NAME
23. ~~~,f,.~~~DO~N-?o~~O~~ ~'ivBg~~i~E DATE 08105I2OO5
This license authorizes the marriage in New York St 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 0 be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERKe. M 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
TIME MONTH YEAR MONTH
SEAL SIGNATURE" DATE 08105I2OO5
'-v-l M~liD Falls NY 12590 10:19 AM 08
STREET CITYITOWN STA ZIP PM
~~~R~:Ri~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27., TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the best of my kno
as to my right to enter intD the ma . . 0<. .
21. SIGNATURE OF GROOM"
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YEAR
2005
10
04 2005
06
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Suffolk
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
29. OFFICI
NAME (P
TITLE
Pastor
8/19/2005
SPECIFY
Isl;p
SIGNATURE
MAILING ADDRESS
350 Ma;n
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) l.J i ~ l i """ !. Tl-t 0 ,... ~ ~...,., (,.1 J' 11:
SIGNATURE..A/~ J( ~ ~
DOH-98 (11/98)
DATE
STATE
31.
NAME (PRINT)
SIGNATURE ..