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COUNTY ~
CITYfTOWN WaPDinaer
~~J~kcJ 1388
~5~I~J~R 63
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brett D. MiRenar
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
AQRmllli~ A Qahhif1SL
MIDDLE CD~~flISURNAME
~
1. A. FULL NAME_
11. A. FULL NAME
FIRST
FIRST
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Misenar:
(OPTIONAL -SEE REVERSE)
D. SOCIAL SECURITY NUMBER C'fl2-72-n80
12. RESIDENCE A. ~1nrlr B. ~rrl
C. CHECK ONE 0 CITY 0 TOWN c;,JILLAGE
~~~CIFY ~ppi'lQP-'K J;III.
D. STREET ADDRESS g1 ~..."I,."Or1Ye ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [jI' YES 0 NO
./ ~
M~ "J;ly ~~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 537 ~ .. ..~
D. SOCIAL SECURITY NUMBER -- -~~
2. RESIDENCE A. ~Erork B. ~P.mr.
C. CHECK ONE 0 CITY 0 TOWN [Y'VILLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 91 Carmine DrIve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? cY'YES 0 NO
3. A. AGE :w 3B. DATE OF BIRTH Mcm / 1~ / ~
4. EMPLOYMENT
A. USUAL OCCUPATION PDlice Officer
B. TYPE OF INDUSTRY OR BUSINESS N Y C Dep.
5. PLACE OF BIRTH MissoulA. Uftftt8nA .
(CITY, STATEfCOU~T~uSA)
6. FATHER
A. NAME Calin Winfield Mi8enar
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME BtmnlA l M H8~
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
o 0
B. HOW DID LAST MARRIAGE END? (3) J:lllIfJIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / otn / ')NV\
MONTH D1!!" ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? [)I1It'ES 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
rIV1nr..1nDn n.JtrJ1 - CouIIIr, New Ynr\ 0
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13. A. AGE 31
13.8. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION ~v~div~ ~eblry
B. TYPE OF INDUSTRY OR BUSINESS Bdnckerbdf & Neuvlll.
115. Pa..ACEOF BJRTH ~T~Y".SA)
16. FATHER
A. NAME ~ r..amlilrilQ
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Rosemlry keRRY
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1
DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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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
o 0
o 0
o 0
1ST
2ND
3RD
4TH
he information I prDvid i:l is
. SIGNATURE OF
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en
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::i
DATE
of the bride and groom named above by any person authorized by New York Domestic
W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only for the purpose of a second or subse uent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR MONTH DAY
YEAR
TIME
MONTH
10:31 AM 08
PM
22
08 20 2004
ZIP
CIVIL
28. PLACE WHERE MARRIAGE OCCURRE~ ~
A. STATE NEW YORK B. COUN~ ~
C. LOCATION OF CEREMONY
(CHECK ONE A~ SPECIFY)
o crr~ri TOWN OF D VILLA
SPECI~~"~ ~
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) ~"l
.
tv y7/'~~.A-
SIGNATURE ~