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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Justin Robert Bourke
CURRENT SURNAME
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(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~J~kc~ 1368
~5~~J~R 79
L D SUPPLEMENTAL FILE
Bank Teller
A USUAL OCCUPATION Mid Hudson Vall feU
8. TYPE OF INDUFltn~ BUStf.'di ey
15. PLACE OF BIRTH 0 lac, ligan
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAME Donald Albert Broome
B. COUNTRY OF BIRTH U ~ A
11. A.
FROM THE BRIDE
FULL NAME Dani Leigh Broome
FIRST MIDDLE
MIDDLE
CURRENT SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), 1~IFFErf(T ...
C. SURNAME AFTER MARRIAGE ou e
(OPTIONAL. SEE REVERSE) 1 "l.1- J u-t>428
o .SDCIAL SE\i.UjlIH NUMBER
2 RESIDENCE ANY B. uutchess
1 . (STATE) J (COUNTY)
C. CHECK Ollii.. JIJ CITY 0 TOWN 0 VilLAGE
AND wappinger
SPECIFY 7 I Witt
u n egae
D. STREET ADDRESS
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)361-68-7382
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. N Y B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK ON~&. D. CITY 0 TOWN 0 VilLAGE
~~~CIFY wappinger
D STREET ADDRESS 1 J Whitegate
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ZIP 12::J9u
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E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Y ~
3 A. AGE 25 38. DATE OF BIRTH 03 /03 /19i:i0
MONTH OA Y YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Computer Consultant
8. TYPE OF INDUSTRY OR BUgrSS I 1 ^ I ecnnologles
5. PLACE OF BIRTH Bloomin on, illinoIS
(CITY, STATE/COUNTRY IF NOT USA)
E. IS RE~4CE WITHIN LIMITS OF CITY OR INCORPORATf1ILLAGE?~7 0
13. A. AGE 13.B. DATE OF BIRTH ~
MONTH OA Y
14. EMPLOYMENT
6. FATHER
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A. NAME Robert Joseph Bourke
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kimberly Marie Negleman
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOBCE CIVil AN~LMENT
DEtj'H
17. MOTHER .
A MAIDEN NAME Deborah Susan SlIpcak
8. COUNTRY OF BIRTH U 5 ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'tjRCE CIVIL ANtflMENT
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
C. DATE lAST MARRIAGE ENDED?
ZIP
12590
.;
Yfp8h NO
YEAR
DEffH
(2) 0 DEATH
MONTH OA Y 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
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
1ST
2ND
3RD
4TH
at the information 1 provided is true and that I d clare that no I
,
o 0
o 0
o 0
o 0
al impediment exists
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1ST
2ND
3RD
4TH
I, being duly sworn, depose
as to my right to enter into t
21.
by New York Domestic
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MONTH
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
DAY
YEAR
A. STATE NEW YORK B COUNTY j)VTC#EfJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VillAGE OF
SPECIFY ~ihAlE.c9Ec.lC.
10
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
CITY /TOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1 Q(.cIVIL
28. PLACE WHERE MARRIAGE OCCURRED
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
NAME (PRINT)
SIGNATURE ~
02 2005