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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Thorn_ Armstrona
FIRST MIDDLE CURRENT SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
COUNTY Dutchess
CITYITOWr:i::PPnrJIif
DISTRICT 1
NUMBEIi
REGISTER .-s
NUMBER
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
11. A. FULL NAME S8n1h 4mn Me NAmNll
FIRST MIDDLE
CURRENT SURNAME
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 054-AQ.~1
12. RESIDENCEA.NewVarIr B. nlllt~
(STA'lt, ~
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
~~CIFY East FIBhIdII
O. STREET ADDREss276 RauI:e 378 AP- D2 ZIP 1~~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 1A 13.B. DATE OF BIRTH ff7 45 "'-A1i.
'mlNTH DAY ~R
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 n7 ~_ftA~
D. SOCIAL SECURITY NUMBER WI.' .I::-u"IU'
2. RESIDENCE A New Y ark B. DutcIle8s
(STATE) J (COUNTY)
C. CHECK ONE ~CITY ~ TOWN 0 VILLAGE
AND 1::--6 ishIcI
SPECIFY E:;IIDI.
D. STREET ADDRESS 276 Route 376 Ad. D2 ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
Cf1 /05 /1971
MONTH DAY YEAR
3. A. AGE 33
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Sales .wmate
B. TYPE OF INDUSTRY OR BUSINESS UnIted Atata& ~,
15. PLACE OF BIRTH Yonkers, New York
(CITY, STATEiCOUNTRY IF NOT USA)
16. FATHER
A. NAME Bernard Calum Me Namee Jr
B. COUNTRY OF BIRT..lJ S A
17. MOTHER
A. MAIDEN NAME SMmn Be'h eot.n
B. COUNTRY OF BIRTJ:"".nd
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATION H V A C Technician
B. TYPE OF INDUSTRY OR BUSINESS HellIng & A. C.
5. PLACE OF BIRTH Bronx. New York
(CITY, STATEiCOUNTRY IF NOT USA)
6. FATHER
A. NAME Rabert~una
B. COUNTRY OF BIRTH ~
7. MOTHER
A. MAIDEN NAME Chaltotte Beer
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVC()'CE CIVIL ANOULMENT
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and S
as to my right to enter into the ma
21. SIGNATURE 'OF GROOM ~
o 1ST
o 2ND
o 3RD
o 4TH
nd belief that the information I provided is true a
(
. SIGNATURE OF BRIDE
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York the' bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit 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 Cll" ~lER~ 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) .JGnn ~. Masterson
{SEAL ~_;.".~ Ol!--('. "1YI~'\ omlJ&l1512l1115 ""' ",. MOmH
'-,-I 2r~ Rd, V\Itippi~ Falls, NY 12590 08 14 2005
STREET CITY/TOWN STATE ZIP
~~~R~~Ri~~~ 10~0~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE CEREMONY
SONS NAMED ABOVE' ON THE TIME MO. DAY YEA
DATE AND AT THE TIME AND AM
PLACE INDICATED~ PM
29. OFFICIANT Jot .,
NAME (PRINT) \I "".
YEAR
1 0 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNJII1'C;),-e..;.\oi
C. LOCATION OF CEREMONY
(CHECK ONE A~9-6'ECIFY)
o CITY OF [!('TOWN OF 0
,.....
SPECIFY ,I;"..c h /() I J
,
VilLAGE OF
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