031
]
o
m
.:.:
'--
~
~
Q)
z
(ft ~
(ij to
l1...
UI
....
Q)
O'J
..,C t:
rEo.. >
Ulo..
wC\'J ct
~ C
gSW-
is _ '" LL
i);l.O ~ LL
~;; ct
~~
uf2
~S
"'10
~O
~
<-
cr=
~
"'Q)
3c
w....
>-0
(3.Q
u:cn
~O
w
()
wID
ffi(')
I ffi
:;; OJ
Ul '"
Ul ::J
W Z
cr: a
a z
a '"
'" ww'"
G: g:
8 (/)
0-
Ul
~
l ~
U
...J
\,
'1/
..
z z
, ~ 8 w
w '" I-
~ ~ <(
~ iB U
~ ~ IT:
~ 3 i=
'u: ex::
~ ~ W
W a U
I- "'
o
z ~
~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM TJ-l E GROOM
Robenc. Fisher) JR.
8 HOW DID LAST MARRIAGE END? (3) 0 DIV01jS (3) ~~NULMENT 1 ~g DEATH
COATE LAST MARRIAGE ENOED? . / . /
MONM DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY OIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
ST mf71llr~9!J~Rpe(ekYsJlill,E/~~Y;YoriT USA) SiiY SPOUSE
1 . 0 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
best of my knowledge and belief that the information I provided is true
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ D
This license authorizes the marriage in New York authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi in 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 CI:}!&lif J. Morse 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
Dutchess
COU"TY .
. W~pplflyt:r
CITY.TOlO/l'l o.
...,'JiSTRICTI.Jt6u
. ',llW,1ER F31
' PEGISTE
'.UMBER
A FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
0-
N
B 81RTH NAME. IF DIFFERENT
C S~~~~~N~LTE~~t~~e~~sE053-62_2221
o SOCIAL SEj;~RITY N\I.I~IIl.EBr. 0'" "'-
New forK UICfless
2 RESIDENCE A. (STATE)~ 8 (COUNTY)
C ~H6CK o\\'appm~er 0 TOWN 0 VILLAGE
SPECIFY 36 O:;burm:: Hill Ruad Lot 5
o STREET ADDRESS
...
E IS R~~NCE WITHiN LIMITS OF CITY OR INCORPORATEmLAGE? .:190 YES f9~~
3 A. AGE 38 DATE OF BIRTH L /
MONTH DAY YEAR
4. EMPLOYMENT B kk
00 eeper
A. USUAL OCCUPATION Bruwflell Molurs
B. TYPE OF IND~TRY .Qtl.ll.IlS,Ms.s N . . k
....OUyr utecpSle t:w, or
5. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER Robert Fisher Sr.
A. NAME U 5 A
B. COUNTRY OF BIRTH
7. MOTHER
Judith Tolson
U~A
B. COUNTRY OF BIRTH 2
8. NUMBER OF THIS MARRIAGE
A. MAIDEN NAME
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL A~ULMENT
D1jTH
'"
21. SIGNATURE OF GROOM ~
~
{ SEAL }
'--v-I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER~
SONS NAMED ABOVE ON THE
DA TE AND AT THE TIME AND
PLACE INDICATED
STATE FilE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
,:iJJJt6
" 1" /)
b ",f /-' tlJ{
Lo
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B 81RTH NAME (MAIDEN NAMEI.F~T
C SURNAME AFTER MARRIAGE n..... ." "'068
(OPTIONAL ~ SEE REVERSE~~'.rZ:
o SOCIAL SN~~~l1t Olltct less
12. RESIDENCE A (ST A TEI..I' 8 (COUNTY)
C ~H6CK Wappmgi!f( 0 TOWN 0 VILLAGE
SPECIFY 3(; Osborne Hill Rood Lot# 5 12590
D. STREET ADDRESS ZIP . "
E IS R~~NCE WITHIN LIMITS OF CITY OR INCORPORATE()~LLAGE? 10 0 Y~9"O
13. A. AGE 13.B. DATE OF BIRTH L L
MONTH DA Y YEAR
14. EMPLOYMENT Registered Nurse
A. USUAL OCCUPATION Fishkill Ambulatory Surgery
B TYPE OF IND~~'ffir ~Vork .
,
15. PLACE OF BIRTH
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER David Flynn
A. NAME USA
B. COUNTRY OF BIRTH
17. MOTHER
Nora Hussey
A. MAIDEN NAME U 5 A
8 COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DtpRCE CIVIL A~ULMENT
DE{1TH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
YEAR
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
22. SIGNATURE OF BRIDE ~
o 0
o 0
o 0
o 0
I impediment exists
, 'Il/~ !
108/2002
TIME
MONTH
YEAR
ZIP
01 :51 ~~ 04
STATE
27. TYPE OF CEREMONY
s)( RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN.::i?I1-rc..~C;-
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFYI
o CITY OF )( TOWN OF =' VILLAGE OF
SPECIFY E AS, FIS HI< ILL
(. H6 PE f.U E L... .:r <. ~. J
TITLE
31.
NAME (PRINT)
SIGNATURE ~
~"
STATE OF New York
} 55
053-62-2221 (Groom)
094-46-2068 (Bride)
Affidavit for
Correction of Marriage Record
FOR OFFICIAL NYS USE ONLY
~~~~;iIR:b q! :.'t: :/;:~ ;V'J
Bride: (~nt".'st-I'r\a. M. ;::"11""'"
Date Completed: X
.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
COUNTY OF Dutchess
We. Robert E. Fisher Jr.
(Groom)
being severally sworn. depose and say that:
and
Christina M. Flynn
(Bride/Maiden Name)
1. We reside at:
36 Osborne Hill Road Lot# 5
2. Marriage License issued by City/Town:
Tn~ nf WAppinger
3. Date of Marriaqe -Ha,v 18. 2002
4. Error(s) appearing on record (list exactly):
a. Christina A. Flynn
b.
c.
5. Correct information as it should appear (list exactly):
a. Christina M. Flynn
b.
c.
6. Documentation Submitted:
a.
Birth Certificate
b.
New York State Drivers License
c.
ThiS affidavit with supporting documentation IS being made for th~P pose of having the record of marriage show ttle
true facts and thiS affidavit will become a permanent record. The rrlage recbrd IS filed with the State of N>:-w Y'Jrh
14.~~
S;g re ~f ~sbandl!;:,r,
!.~ ,U (i'
r' of
Subscribed and sworn to
(affirmed) before me this
-;' '- L,'t,
"
,07I:'C~
c
Notary Public
----
GLORIA JEA~ tJORSE
IlclalY Public, St.-tI III IIeW York
Qunlllled In LV5:IlIsS CauaIJ 47~1~
Comm. EJ\1IItI Aua. 31.~
(over)
.<
NOTE: Certificate of Authenticity'requ!r d for notary publ" outside New York State
/
V"
DOH-1827 19/98\
.
."11'\11 STATE OF NEW YORK
., DEPARTMENT OF HEALTH
Corning Tower
The Governor Nelson A. Rockefeller Empire State Plaza
Albany, New York 12237
Antonia C. Novello, M.D., M.P.H., Dr.P.H.
Commissioner
Dennis P. Whalen
Executive Deputy Commissioner
November 27,2002
Gloria 1. Morse, Clerk
20 Middlebush Rd.
Wappinger Falls, NY 12590
Groom: Robert E. Fisher, Jr.
Bride: Christina M. Flynn
Enclosed is a copy of the marriage referred to by the above file in your office.
Correction to the original has been made based on:
XXX Affidavit
- -
Court Order
Officiants Statement
Signature on original marriage affidavit
Statement verified by City/Town Clerk
Other: Supplemental
Please file this amended record along with the supporting documentation.
Sin~ly, ~
/f~~~;~J:L
RECEIVED
New York State Dept. of Health
Vital Records Section
PO Box 2602
Albany, NY 12220-2602
Enclosure
DEI 0 2
fOWN. ,. (;1 F")
. '. ..",hl-\