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_.~"~._- .._,--~- -._-~----_.._-- ,---.--.,,------- .----. -----,-~~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM .
ErikM ~
MIDDLE CURRENT SURNAME
1ST 0 0 0
2ND 0 0 0
3RD 0 0 0
4TH
I, being duly swom, depose and say
as to my right to enter into the m . e
21. SIGNATURE OF GROOt,II ~
23. ~~~-m=~Do~-f=~ ~B~=~E
This license authorizes the marriage in New York State of tlie 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
GI . . .
COUNTY Dutchess
CITYITOWN WBpr;inger
~~J~~CJ 1~
~G~lgJ~R 145
1. A. FUll NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ~
D. SOCIAL SECURITY NUMBER 429-A~, -'LU'"
2. RESIDENCE A. N V B. I'lt~
(s'I'.m) ~
C. CHECK ONE 0 CITY []hOWN 0 VILLAGE
AND D-uwha--i
SPECIFY r-vr-~e
0, STREET ADDRESS 25 Carmen DrIve ZIP 12803
IS RESIDENCE WITHIN UMITS OF CI1Y OR INCORPORATED VILlAGE? 0 YES rI NO
w11I / a, / yiFT
E.
3. A. AGE 26
4. EMPLOYMENT
A. USUAL OCCUPATION RiI!!hIiI
B. TYPE OF INDUSTRY OR BUSINESS Staples
5. PLACE OF BIRTH Gratan t'~
(crrv,STA~
6. FATHER
A. NAME Ch~ Jonath8n BerlJen
B. COUNTRY OF BIRTH USA
3B. DATE OF BIRTH
7. MOTHER
A. MAIDENNAME ~._Cb8~'
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
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT' (2) t] DEATH
/ /
C. DATE LAST MARRIAGE ENDED?
_. 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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
r
STATE FILE NUMBER
(THIS SPACE FOR STATEUSE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
R~ L Ri~=SURNAME
~
11. A. FUll NAME
FIRST
e, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bergen
(OPTIONAL' SEE REVERSE) 1~"7'" ftft"Vt
D. SOCIAL SECURITY NUMBER -~~
12. RESIDENCE A. N V B. I'lt~
---"-(stATE) ~
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND 0.... uwh"--i
SPECIFY r-...,..~e
D. STREET ADDRESS 50 stej;)h8n1e Lane ZIP 12603
E, IS RESIDENCE WITHIN C"MITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 19 13.B. DATE OF BIRTH 01 / OR AQfW
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Retail
B. TYPE OF INDUSTRY OR BUSINESS Petco
15. PLACE OF BIRTH ~JoNs!
16. FATHER
A. NAME Robert Rance Rightmyer
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lpn ~I, K_A
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
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
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
w
en
z
w
o
::i
1 1
Falls NY 12590
WN SA
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOlEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29.0FFICIANT ~ ~
NAME (PRINT) -. f\I
SIGNATURE'- :.:...~. ., ~
MAILING ADDRESS
43 g3 AI-BAI\JY POST RD. , NY
STREET CITYITOWN .
30. WITNESS TO C
TITLE
"ATE.
NAME (PRINT)
SIGNATURE .-
€A'...
TIME
MONTH
YEAR
IP
AM
03:()4>M
10
28. PLACE WHERE MARRIAGE OCCURRED
1 [j(' CIVIL
A. STATE NEW YORK B. COUNTY :t>iJ1Z.I..f6SS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ri'TOWN OF 0 VILLAGE OF
SPECIFY Fbu~HI!.IECPSIE
/Dill/AI Jusnc. e
1I1/~;/()3
, ,
STATE