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1. A. FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Tyler ~~gtt Beau ~~m~m~'RNAME
FIRST
COUNTY Dutchess
CITY/TOWN WappinQer
~~J~~c: 1368 .
~5~:~R 10
011-\11::. rn..c l'\IUMDCn
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jaclyn Ruth Peck
MIDDLE CURRENT SURNAME
~
11. A. FUll NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 391-04-5627
2. RESIDENCE A WI B. Winnebago
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Clayton
D. STREET ADDRESS 8020 Pleasent Valley Rd ZIP 54947
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE ?1 3B. DATE OF BiRTH 01 / 14 /1989
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Murphy
(OPTIONAL. SEE REVERSE)1 01-76-3219
D. SOCiAl SECURITY NUMBER
12. RESIDENCE ANY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
AND W .
SPECIFY a~lnger
D. STREET ADORES Farms End Kd
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE20 3B. DATE OF BIRTH 01 ~5
ZIP 1 ~b~U
DYES '6 NO
;t990
YEAR
MONTH
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Army
B. TYPE OF INDUSTRY OR BUSINESS Military
5. PLACE OF BIRTH Outagamie. WI
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME .Joel David Murphy
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Sherry Kay Bork
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
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS FLSM
15. PLACE OF BIRTH Poughkeepsie, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME SterlinQ Joseph Peck
'B. COUNTRY OF BIRTHU SA
17. MOTHER
A. MAIDEN NAME Deborah Ann Moser
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. ~~~~~~;RMtFR~~AE<t~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DE~TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.,- YEAR
B. HOW DID lAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY/COUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~H 0 0 ~H
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the marrrage state.
21. SIGNATURE OF GROOM,- ~ / 22. GNATURE OF BRIDE~
USE RR
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 ~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 onl for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
TIME MONTH YEAR
SEAL SIGNATURE~ DATE 02/22/201
MAILING ADORE AM 2
'-v-I Mi in ers Falls NY 12590 01 :54>M 0
STREET CITYITOWN STATE ZIP
~~;R~~RTr~J 'o~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. Y YEAR 0 0 RELIGIOUS ~CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
o 0
o 0
o 0
o 0
impediment exists
DATE
by New York Domestic
MONTH
YEAR
23
2010
04
23 2010
28. PLACE WHERE MARRIAGE OCCURR~ .
A. STATE NEW YORK B. COUNTY~/{ c.k~<:J
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
OWN OF 0 VILLAGE OF
NAME (PRINT)
SIGNATURE~