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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Patrick James 8ra~
MIDDLE CURRE SURNAME
COUNTY Dutchess
CITYITOWN Wappinger
13SB
42
DISTRICT
NUMBER
REGISTER
NUMBER
1. A. FULL NAME
FIRST
D-
N
8 BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL " SEE REVERSE) OS') ~D0154
D. SOCIAL SECURITY NUMBER _~___
2. RESIDENCE A. N V
(STA"tE)
o CITY 0 'If OWN 0 VILLAGE
Union Vale
D STREET ADDRESS 3472 Route 82
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
B.
Qutchess
( OUNTY)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Emilv Louise Mudge
MIDDLE CURRENT SURNAME
~
C. CHECK ONE
AND
SPECIFY
ZIP 12545
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~o
1// /4 / 198
MONTH DAY YEAR
3. A. AGE
22
3B. DATE OF BIRTH
11. A. FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Brady
(OPTIONAL, SEE REVERSE) 101 74 6165
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 ~LLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 80 Paggi Terrace ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 ~ES 0 NO
02 / 26 /1983
MONTH DAY YEAR
13. A. AGE
21
13.B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Military
B. TYPE OF INDUSTRY OR BUSINESS U S Marine Corps
5. PLACE OF BIRTH Croton- On- Hudson. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert Daniel Bracty
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Darlene Marie Sindair
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
DEATH
o
14. EMPLOYMENT
A. USUAL OCCUPATION Program Manager
B. TYPE OF INDUSTRY OR BUSINESS People, Inc.
15. PLACE OF BIRTH Newburgh. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME David Eugene Mudge
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Amy Rae Kaufman
B. COUNTRY OF BIRTH USA
1
lB. 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 (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
1ST 0 0 1ST D 0
2ND 0 0 2ND D 0
3RD 0 0 3RD D 0
4TH 0 0 4TH D 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the mar' estate. _
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{ SEAL }
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NAME (PRlt!].
SIGNATURE ~
MAILING AD.ofl.E~Sb
20 MICKIe
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER,
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 0511
8~~~r Falls, ~Ye 12590z1P
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR
l/oQ)~
23. SUBSCRIBED AND SWORN BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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
ri J.
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
1312004
by New York Domestic
TIME
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MONTH
YEAR
AM
12: 1181
05
1j1f CIVIL
28. PLACE WHERE MARRIAGE OCCURRED I
A. STATE NEW YORK B. COUNTY DI,f~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY ~prdY9 ~
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