010
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William.I Rrown
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITY;TOWN Wappinger
~~~~~CRT 1368
~~~'€~~R 10
A FULL NAME
FIRST
BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 081-? 4-9800
RESIDENCE A N Y B IJutches!=i
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D STREET ADDRESS 47 Riverview Drive
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A, AGE 68 3B DATE OF BIRTH
ZIP 12524
DYES roIf NO
MO
4, EMPLOYMENT
A, USUAL OCCUPATION Retired
B, TYPE OF INDUSTRY OR BUSINESS
5, PLACE OF BIRTH Yonkers New York
(CITY, STATElcbUNTRY IF NOT USA)
6 FATHER
I- A, NAME .lm;pph r.h::lrlp!=i Rrnwn
:;: B, COUNTRY OF BIRTH I J S A
<(
C 7 MOTHER
u:: A, MAIDEN NAME Elizabeth Hogan
LL
<( B, COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
~jl~t
II;" .( lJ
i 'CI\ tJ 'l1i
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
Eileen MarY' Rrnwn
FIRST MIDDLE CURRENT SURNAME
8, BIRTH NAME (MAIDEN NAME), IF DIFFERENT _Me rJermott
C SURNAME AFTER MARRIAGE Rrown
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 1 OO-?O-O~?n
12 RESIDENCE A, N Y B IJtJtehes!=i
(STATE) (COUNTY)
C CHECK ONE 0 CITY cYTOWN 0 VILLAGE
~~~CIFY Fishkill
D STREET ADDRESS 47 Riverview Drive ZIP 12524
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r'f NO
MQ.~ / t~ /1 ~?l
11 A, FULL NAME
13 A, AGE 74
13.B. DATE OF BIRTH
14, EMPLOYMENT
A USUAL OCCUPATION HotJ!=iewife
B. TYPE OF INDUSTRY OR BUSINESS
15, PLACE OF BIRTH Queens New York
(CITY, STATEiC~OUNTRY IF NOT USA)
16. FATHER
A, NAME Frlw::lrn Me Oermn\i
B COUNTRY OF BIRTH USA
17, MOTHER
A. MAIDEN NAME Mary Messett
B COUNTRY OF BIRTH l J S A
18. NUMBER OF THIS MARRIAGE 2
19 PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
DEATH
1
(2) D"tEATH
1999
YEAR
o
B, HOW DID LAST MARRIAGE END? (3)::J DIVORCE (3) 0 ANNULMENT
C, DATE LAST MARRIAGE ENDED? 06 / 01 /
MONTH . t;jAY
D ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ['fNO
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
D 0
c 0
D [J
0 0
:E 0 0
OJ 0 0
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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 State of the bride and groom named above by any person authorized
Relations Law S11 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
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NAME (PRINT)
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01/22/2002
by New York Domestic
TIME
MONTH
YEAR
MONTH YEAR
10:49AM
PM
01
23
200
03 23 2002
1~CIVIL
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY 7J1fre.fff;.~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF C VILLAGE OF
SPECIFY tUfffJPI M-&:F2-
ZIP
31, WITNESS TO CEREMONY
NAME (PRINT) L
SIGNATURE ~