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COUNTY ~
CITY/mWN Wappinger
~~J~~c~ 1388
~5~~J~R 154
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~d M .1By=EHT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~U~hdstia~RENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
c.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) "",,""... "3524
D. SOCIAL SECURITY NUMBER tD~~___-J
2. RESIDENCEA. lIfa)Vnrk' B. ~P.!mI.
C. CHECK ONE 0 CITY 0 TOWN OI\fILLAGE
~~~CIFY Wappingers ~alIA
D. STREET ADDRESS 8211 Prlnoess Clmle
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~S~JJ,.~~~~~~O~~SE) Christiansen - Jayner
D. SOCIAL SECURITY NUMBER 087 ...ss..9695
12. RESIDENCEA'~!1\VE;tDdc B. ~es.
C. CHECK ONE 0 CITY 0 TOWN 0 -'ILLAGE
~~~CIFY WSlppingem Falls
D. STREET ADDRESS 6?11 Pdnoess Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? ~ES 0 NO
MO~ / 1.1 /1W~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE?
3. A. AGE 31 3B. DATE OF BIRTH
4. EMPLOYMENT
ZIP 125M
~ES 0 NO
M
13.B. DATE OF BIRTH
A. USUAL OCCUPATION A~istant Manager
B. TYPE OF INDUSTRY OR BUSINESS Henaford Supermarket
13. A. AGE 2-1
14. EMPLOYMENT
A. USUAL OCCUPATION Homemaker
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH~YuWk
16. FATHER
5. PLACE OF BIRTH
6. FATHER
I ,
A. NAME Bradley Henry Jayner
B. COUNTRY OF BIRTH I) SA
7. MOTHER
A. MAIDEN NAME Mary Ellen Eklrke
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
A. NAME Annas CtuistiSRS8A
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME elaine EwAS
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
DEATH
o
(2) 0 DEATH
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNUUMENT
/ /
(3) 0 ANNUUMENT
/ /
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
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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
and belief that the information I provided is true and that I declar
D 0
D 0
D 0
o 0
pediment exists
.
21. SIGNATURE OF GROOM ~
22. 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 ate of 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-'
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
AM
PM
11
08
01
04 2004
ZIP
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
~IVIL
29. OFFICIANT
NAME (PRINT)
(CHECK ONE AND SPECIFY)
D CITY OF~OWN OF 0 VILLAGE OF
SPECIFY \1 '1r Pf ~ II... ~ r