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COUNTY Dutchess
C1TYiTOWN Wappinger
1368
30
~ I A I t:. Ut- Nt:.W YUHK.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bryan A. Wirsch
MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
.af!1"~
J!i /}
if' ci if / tl .l\.
DISTRICT
NUMBER
REGISTER
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Laura A Broun
MIDDLE CURRENT SURNAME
.~
1 A. FULL NAME
11. A. FULL NAME
FIRST
B 81RTH NAME (MAIDEN NAME). IF DIFFERENT Broun
C SURNAME AFTER MARRIAGE Wirsch
(OPTIONAL. SEE REVERSE) 103 68 5902
o SOCIAL SECURITY NUMBER --
12 RESIDENCE A New York 8 Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY O-.lfOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 13 Vanderwater Avenue ZIP 12603
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 097-64-4482
o SOCIAL SECURITY NUM8ER
2 RESIDENCE A New York B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY [)"'TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 13 VandelWater Avenue
12603
ZIP
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' 0 YES &NO
3 A. AGE 30 3B. DATE OF BIRTH O? / ?5 / 197 13 A AGE ?R 13.8 DATE OF BIRTH 05 / O~ /1975
MONTH DAY YEAR MONTH DAY YEAR
4 EMPLOYMENT
14, EMPLOYMENT
A USUAL OCCUPATION Homemaker
B TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Pouahkeeosie. New York
(CITY, s'fATElcOUNrny IF NOT USA)
16, FATHER
A NAME Joseph Broun
B, COUNTRY OF BIRTH USA
17, MOTHER
A MAIDEN NAME Patricia Collins
B COUNTRY OF BIRTH USA
18, NUMBER OF THIS MARRIAGE 2
A USUAL OCCUPATION Building Maintenance
8 TYPE OF INDUSTRY OR BUSINESS Poughkeepsie Nissan
5. PLACE OF BIRTH Rhinebeck. New York
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A, NAME Barrv Wirsch
B COUNTRY OF BIRTH USA
7 MOTHER
Michele Dalbo
B COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 1
A. MAIDEN NAME
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH 8 HOW DID LAST MARRIAGE END? (3) 0 ~VORCE (3) 0 ANNULMENT
/ / C DATE LAST MARRIAGE ENDED? 11 / 30 /
MONTH DAY YEAR MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D, ARE ANY FORMER SPOUSE(S) ALIVE? O"",ES 0 NO
1 O. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20, IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 11/30/2000 Poughkeepsie, New York 0 0.....
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
Dwledge and belief that the information I provided is true and that I declare that no legal impediment exists
22 SIGNATURE OF BRIDE;~ ~~ .--I~.-f /J...--LA.A..---,.
~ USE CUl'l<l~AME ----
04/05/2002
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
C, DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
2000
YEAR
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say,
as to my right to enter into the mar.~a
23
21 SIGNATURE OF GROOM ~
K~ M~
This license authorizes the marriage in New York authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit 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 CITY CLERK 25. A, SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ~'o' . TIME MONTH
SEAL SIGNATURE ~ 04/05/200
'-v-I MAI~ ~CfJrebush Rd. 12:2;~ 04
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY .lJitTdrJJ
10 CIVIL
29. OFFICIANT
NAME (PRINT)
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY ..fd,l/fJk~~
ZIP
31, WITNESS TO CEREMONY
NAME (PRINT) /l7
SIGNATURE ~