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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
.J
,. A. FULL NAME
RO'ijE'lr Frank Fra~
IOOLE CU RENT SURNAME
FROM THE BRIDE
Cynthia Ann Forrest
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAMEl,lF DIFFERE~ichardson
C. SURNAME AFTER MARRIAGf. ra ry
(OPTIONAL. SEE REVERSel68-46-5537
D. SOCIAL SECURITY NUMBER
12. RESIDENCE NY put chess
(STATE) J (COUNlY)
C. CHECK ONE 0 CITY ~ TOW~ 0 VILLAGE
AND \A/' II
SPECIF'f ..!. aP..Eln~ers a s
D. STREET ADDREB2 McKinley ::;t
11, A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSI;l.
D. SOCIAL SECURITY NUMBER u27 -34-837 4
2 RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN"'O VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS62 McKinley St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGF61 3B.DATEOFBIRTH 05 /28 ~948
MONTH DAY YEAR
MONTH
'12590
ZIP
v
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
06 95
DAY
3B. DATE OF BIRTH
YiS~2NO
YEAR
13. A. AG~7
4, EMPLOYMENT
A. USUAL OCCUPATION T E'lar.her
B. TYPE OF INDUSTRY OR BUSINESS Birch Wathen Lenox School
5. PLACE OF BIRTHNorthamnton, Ma
(CITY, STATE /OOUNTRY IF NOT USA)
6. FATHER
A. NAME Fra'1k Taylor Frary, Jr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Caroline Hall
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MAR81AGE 3
14. EMPLOYMENT
A. USUAL OCCUPATIOJ"eacher
B. TYPE OF INDUSTRY OR BUSINESparnson Ut-::;U
15. PLACE OF BIRT.Queens, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEN!organ Schuart Richardson, Jr
'B. COUNTRY OF BIR.J.J S A
17. MOTHER
A. MAIDEN NAM~arilyn Joan Burkel
B. COUNTRY OF BIRT.!rl S A
lB. NUMBER OF THIS MARRIAGE 2
9. ~~~~~~~R~"FR~~~~8us MARRIAGES WHICH ENDED BY 19. ~~~~~~~R~FR~ItE~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH D11VORCE CIVIL At:!NULMENT D~TH
? 0 0 u U
B. HOW DID LAST MARRIAGE END? (3)~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3)'6 DIVORCS (3) ~~NULMENT 19~~ DEATH
C. DATE LAST MARRIAGE ENDED? 06 / 12 / 1997 C. DATE LAST MARRIAGE ENDED? 0 / /
MONTH DAY YEAR MONlll' DAY, -. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? i!!f YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STA!E/COUNTRY, IF NOT USA) SELF SP~SE
1ST OR/1 "1997 Mineola, Ny 0 tJ 1ST 06/28/1995 Putnam Co, NY 0 0
2ND 07/27/1989 Mineola, Ny 0 tJ 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided Is tru nt exists
as to my right to enter into the mama tate. .
21. SIGNATURE OF GROOM ~
USE CURRENT
23. SUBSCRIBED AND SWORN TO/AFFIRMED B FORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named abov y any person authorized
Relations Law !l11 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
by New York Domestic
,-A-..
{ } NAME (PRINT)
SEAL SIGNATURE.
MAILING ADDRESS
'-v-I '
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
MONTH
YEAR
TIME
MONTH
03:28~~ 05
05
2010
07
03 2010
l~VIL
28. PLACE WHERE MARRIAGE OCCUR~D f J I
A. STATE NEW YORK B. COUNTY NJ ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE.