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11.
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bryan R.
FIRST MIDDLE
o 1ST 0 0
o 2ND 0 0
o ~ 0 0
o 4TH 0 0
lief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~~rrl\ ~r
.. ~URRENT NAME
DMEAu~. 11. 2004
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 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
{ } NAME (PRINT) Glo
TIME MONTH DAY YEAR MONTH DAY YEAR
SEAL SIGNATURE ~
'-v-I ~~LI1.1ta~f~ }S1
STREET 3: 00 PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
COUNTY
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappin2:er
1368
96
:>>1".1: rll..c nUMDl;;n
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULLNAME Danielle M.
-.J
1. A. FULL NAME
Jacobs
CURRENT SURNAME
FIRST
MIDDLE
Bronco
CURRENT SURNAME
D-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE)
C. CHECK ONE. 0 CITY IX TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 2565 South Road
ADt. :'::bB
E. IS RESIDENCE WITHIN LIMITS OFtlTY OR INCORPORATED VILLAGE?
3. A. AGE 25 3B. DATE OF BIRTH 08 /
MONTH
DAY
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Jacobs
(OPTIONAl- SEE REVERSE) 130 60 7829
D. SOCIAL SECURITY NUMBER - -
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY Ki TOWN 0 VILLAGE
~~CIFY Pou~hkeepsie
D. STREET ADDRESS 2565 South Road ZIP 12601
E. IS RESIDENCE WITHIN LIMITS ol~Jj)ytoA INto~P~RATED VILLAGE? 0 YES Ii NO
13.A. AGE 26 13.B.DATEOFBIRTH 11 /17 /1977
MONTH D~ Y~R
14. EMPLOYMENT
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESS Roses Florist of Fishkil
15. PLACE OF BIRTH Poughkeepsie. Ne. w York
(CITY, STATE/COUNTRY IF N15T USA)
16. FATHER
A. NAME Joseph Thomas Bronco
B. COUNTRY OF BIRTH U. S. A.
Florist
17. MOTHER
A. MAIDEN NAME
Cynthia Ruth
U. S. A.
First
Benzin~
105-70-6299
B. Dutchess
(COUNTY)
ZIP 12601
DYES}g NO
21 /1978
Y~R
4. EMPLOYMENT
A. USUAL OCCUPATION Retail
B. TYPE OF INDUSTRY OR BUSINESS Walmart Dept. Store
5. PLACE OF BIRTH Pou~hkeepsie. New York
(CITY, STATElCOUNTRV IF NOT USA)
6. FATHER
A. NAME Elliot Charlton Jacobs
B. COUNTRY OF BIRTH U. S. A.
7. MOTHER
A. MAIDEN NAME Linda Elizabeth Smith
B. COUNTRY OF BIRTH En~land
8. NUMBER OF THIS MARRIAGE Firs t
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY Y~R
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 Y~R
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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25. B. SOLEMNIZATION. PERIOD
ENDS AT MIDNIGHT ON:
08
12
2004
10
10
2004
1)d CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY pt/lZ'#.s1
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~~OWN OF 0 VILLAGE OF
SPECIFY /I)fJ,PjOl Af(:-E../J..,