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STATE OF NEW YORK
DEPARTMENT OF HEALTH
. . ~FFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William Ryan Ben::jener
MIDDLE CURRENT SURNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swe!3r/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my nghtto enter Into the marriage state. . .l\ J ~
21. SIGNATURE OF GROOM~ I ~ r). 22. SIGNATURE OF BRIDE~ 9 JQ/if\..J\..!Y1 (laMllf..
us UR USE CWENT AME'1::':::
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M 06/02/2010
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masterson
{I 06/02/2010 TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~ DATE
I..-~ MAUJ~G Is, NY 12590 AM 06 03 2010 08 012010
--v- LV 03:23 PM
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.
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368
~5~~~~R 57
1. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)1 08-66-9233
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY'tJ TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 1 West Hook Rd ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES "0 NO
01 /05 /1983
DAY YEAR
3. A AGE27
36. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Laborer
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH North Tarrytown, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME William Robert Bergener
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Bonnie Jo Laibler
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEAJH
C. DATE LAST MARRIAGE ENDED?
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
0::'
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STATE FilE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sarah Anne McKeegan
MIDDLE CURRENT SURNAME
-1
11. A. FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bergener
(OPTIONAL - SEE REVERSE()75-76-5366
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANY BDutchess
(STATE).L- (COUNTY)
C. CHECK ONE .D crr)' .LJ TOWN 0 VilLAGE
~~~CIFYEast rlshKl1I
o STREET ADDRESS' West HOOK KO
lLbjj
ZIP
.t.
o YES 0 NO
)'989
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A. AGE20 3B. DATE OF BIRTH 07 )'1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIONGrocery Clerk
B. TYPE OF IND~TRY OR B,!Jl'INESsRetall
15. PLACE OF BIRTHl:Sronx, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEDaniel Michael McKeegan
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Ruth Louise Scozzari
B. COUNTRY OF B;;;JJ S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A~ULMENT
D'Q'TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'.- YEAR
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) ICITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY'lJufclJess
28. PLACE WHERE MARRIAGE OCCURRED
1 fB"'CIVIL
TITLE leeva-efJd
DATE 1;/1 ~/;O
A/ Y /25'33
STATE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF if TOWN OF 0 VILLAGE OF
SPECIFY Etisl T/shh//
SIGNATURE~
DOH-9B (0312006)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) A I
SIGNATURE