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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
MiCh~I:P~~ ~~M
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
Dutchess
COUNTY v.pp
CITY/TOWlll RgaII
DISTRICT ,.368
~~~~~~R 49
NUMBER
-.J
CURRENT SURNAME
L 0 SUPPLEMENTAL FILE
. . FROM Tt-lE BRIDE
Pab'iCl8 A. DOYle
FULL NAME
FIRST MIDDLE
CURRENT SURNAME
11. A.
MIDDLE
FIRST
B. BIRTH NAME (MAIDEN NAME), "[liy'~T
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1~0a-4729
D. SOCIAL SE~V&1c -
12. RESIDENCE A. 8. [}UICheS8
(STATE)" (COUNTY)
C. ~~6CK 01="1Ihki . CITY 0 TOWN 0 VILLAGE
SPECIFY \0& ~'IV HlI Auad
D. STREET ADDRESS ZIP
E. IS RE2CE WITHIN LIMITS OF CITY OR INCORPORATiiIULAGE?"", 0
13. A. AGE 13.B. DATE OF BIRTH ~
MONTH DAY
14. EMPLOYMENT
\2524
.;
1)7600
YEAR
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N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) u87 .:Jt)-~1
o SOCIAL SECW\lIY.. ~~~~R
NeW TOIk DUtCIleIS
2. RESIDENCE A. B.
(ST ATE)" (COUNTY)
C. ~~6CK ON\NaPPirteP TOWN 0 VILLAGE
SPECIFY 81:b~ lid;!"
D. STREET ADDRESS If
E.
12!S1O
.;
Y/~1I4
YEAR
Field Techrician
A. USUAL OCCUPATION M. O. C. eu...JtI~
B. TYPE OF INDU~EI.'Ui~ ~.. It
'-"UIUgp... ~ UJ
15. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Robert Doyle
A. NAME USA
B. COUNTRY OF BIRTH
ZIP
IS RES~CE WITHIN LIMITS OF CITY OR INCORPORATED ~~GE? ~
3. A. AGE 3B. DATE OF BIRTH /
MONTH DAY
4. EMPLOYMENT
Techrician
A. USUAL OCCUPATION M . O. c. eu......
B. TYPE OF INDU_.SIMiw VUl'~ IV
5. PLACE OF BIRTH It
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER Edward Chades Pardee
A. NAME USA
B. COUNTRY OF BIRTH
17. MOTHER SUsan Mensler
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'fRCE CIVIL A'1fLMENT
DectH
7. MOTHER ~ I M--.....ch
A. MAIDEN NAME WVI_I, rene ~I
B. COUNTRY OF BIRTH U S,A
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVcaCE CIVIL AN~LMENT
D~H
....
B. HOW DID LAST MARRIAGE END? (3) 0 D1VOtiS (3) ~NULMENT200Z DEATH
C. DATE LAST MARRIAGE ENDED? ffI / /
MONT 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
~)~YIUit&k S~FSPO~
o 0
o 0
o
t exists
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
YEAR
MONTH DAY
D. AR,E ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that t t
as to my right to enter into the marriage st e
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
est of my knowledge and belief that the information 1 provided is tr
ae
DATE
by New York Domestic
w
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(,)
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23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of he bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New ork 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 CIT 'to Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
YEAR
~
{ SEAL}
'-y-I
TIME
MONTH
NAME (PRINT)
22 2005
01:13~~ 08
STATE ZIP
27. TYPE OF CEREMONY ./
o 0 RELIGIOUS 1 iV'" CIVIL
9 0 OTHER, SPECIFY
08
~ 12590
28. PLAC~ WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE ANYSPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
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(,)
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29. OFFICIANT
NAME (PRINT)
SPECIFY
TREET ITY/TOWN
30 WITNESS TO CEREMONY
NAME (PRINT) /L- e:-pP ,4-A..-D 6~
SIGNATURE ~ "t:.. "C, _ ~
DOH.98 (11/98)
31.
SIGNATURE ~