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COUNTY Dutchess
CITYrTOWN Wappinger
~~~~~CRT 1368
~5~~J~R 115
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Martin L Brundaae
MIDDLE CtJI'lRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. FUll NAME
Nancy A. Reed
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Rizzo
C. SURNAME AFTER MARRIAGE Brundage
(OPTIONAL. SEE REVERSE) 1 02 54 8853
D. SDCIAl SECURITY NUMBER --
12. RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 2088 Route 9 D ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
08 /21 /1968
MONTH DAY YEAR
11. A. FUll NAME
FIRST
a.
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 166
D. SOCIAL SECURITY NUMBER 115-42-3
2. RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY !!"t TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 2088 Route 9 D
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE'
3. A. AGE 55 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Truck Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Bottini Fuel Oil
5. PLACE OF BIRTH Beacon, New York
(CITY, STATE/COUNTRY IF NOT USA)
ZIP 12590
o YES 11 NO
13. A. AGE 33
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATiON Bus Driver
B. TYPE OF INDUSTRY OR BUSINESS Wappinger Cntrl. Schls.
15. PLACE OF BIRTH Cornwall, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
16, FATHER
A. NAME Ralph Rizzo
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nancy Acquaro
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
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S;
<C
A. NAME Martin L. Brundage. Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Bertha Snow
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREViOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
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B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12 / 08 / 1986
MONTfLo DAY
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 12/08/1986 Poughkeepsie. New York 0 d'
2ND 0
3RD 0
B. HOW DID LAST MARRIAGE END? (3) D"'DIVORCE (3) 0 ANNULMENT (210 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 27 / 1996
MONTI-V 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. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
03/27/1996 County Of La Paz, Arizona 0\1'
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YEAR
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat 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 Clrt' CLE.RK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glor: a
{TIME MONTH DAY YEAR
SEAL SIGNATURE ~ DATE 07/26/2002
'-v-I M~~~D r~bush Rd er Falls, NY 12590 01 :54~~ 07 27 200
STREET ,TOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- ./
SONS NAMED ABOVE ON THE 1 [j?"'" CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED.
tJ,,, ,;;I~L
OATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
MONTH
DAY
YEAR
09
24 2002
28. PLACE WHERE MARRIAGE OCCURRED
o 0 RELIGIOUS
, b:J.- 9 0 OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY NIi,V uJnk.".
29. OFFICIANT
NAME (PRINT)
olslw/J
,
OL 1l~:J ~
TITLE
SIGNAT
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Affidavit for
Correction of Marria e Record
FOR OFFICIAL NYS USE ONLY
, J '" j (/)'
STATE OF ivt;,;,f/ /C.cIC
COUNTY OF !)[rlc:llcss
} 55,
We, Martin L. BrundaJ!e
(Groom)
being severally sworn, depose and say that:
and
State File #
Groom:
Bride:
Date Completed:
Nancy A. Reed
(Bride/Maiden Name)
1 , We reside at:
2088 Route 9D, Wappingers Falls, New York 12590
2. Marriage License issued by ~!Town:
Town of Wappinger
3. Date of Marriage
August 2, 2002
4. Error(s) appearing on record (list exactly):
a.
(3B) 01/23/1947
b.
c,
5. Correct information as it should appear (list exactly):
a. (3B) 01/23/1949
b,
c.
6. Documentation Submitted:
a.
State of New York Certification of Birth
b.
c.
This affidavit with supporting documentation is being made for the purpose of having the record of marriage show the
true facts and this affidavit will become a permanent record. The marri Jgejecord is filed wi the State of New York.
t~ 1-
Q' ffiureofHusband
J:(\A,-.(l~ \ ()
~i ,a ure ,Of Wife \
Subscribed and sworn to o1ft ._ " ()
(affirmed) before, me tb,is ~ _, day of f.J.JJ.)I
~ ~ MARIA GILBRIDE . .;,;~.t
Notary P"blic. State of New VorI1 :J'~ ~r
Notary Public Za:d "W{J!.~ Re~ .0, OIG15081374 ,"'''l>;:
.~Qualifled in Dutchpss Co~ty;:.'" ';;..
Commission Expires Nov. 3. .:::cooS
NOTE: Certificate of Authenticity required for notary public outside New York State
12) Q' Cl n
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,;JOu!
(over)
DOH-1827 (9/98)