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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Miirtil3lfo[;mcis Baib~~~~uRNAME
21. SIGNATURE OF GROOM~
USE CURRE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St of the bride and groom named above by 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
DATE 07/12/2010
in ers Falls NY 12590
STREET ITYIT WN STATE ZIP
~~~R~~~Ri~~~ lo~O~~~N~Zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 MRELIGIOUS
DATE AND AT THE TIME AND ") AM
PLACE INDICATED. :J {f/;" 7 \ ~ 10 9 0 OTHER, SPECIFY
~~~li~~~T ~obt...t .B. Rrge. en' TITLE Ci4-->>.ol;, p(l~S"+
SIGNATURE~~. _ DATE 7JI~/,o
MAILING ADDRESS
ID3J&t,K~.,s+. Bo~L F.Sh ,'1/ N\f
STREET CITYrrOWN STATE
30. WITNESS TO
COUNTY Dlltchess
CITYrrOWN \NBppil1OAr
~~~:~c; 1368 .
~~~li~~R 80
1. A FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 471-9A.-:i:iFifi
2. RESIDENCE A. NYsTATEI B. q~~R)ess
C CHECK ONE 0 CITY,JlJ TOWN 0 VILLAGE
AND \^' .
SPECIFY applnger
D STREET ADDRESS 1!1 N~nr.y~IAen Orive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
MoQl / ~9 / JE~R80
3. A AGE 29
4. EMPLOYMENT
A. USUAL OCCUPATION Drafting SIIpen/isor
B TYPE OF INDUSTRY OR BUSINESS Iltility
5. PLACE OF BIRTH RochAstAr MinnA~nt~
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
A NAME Martin Francis Bailey, Sr
B. COUNTRY OF BIRTH I ) S A
7. MOTHER
A. MAIDEN NAME \Iiroini~ M~riA Kln~e
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o
o
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 ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
a:
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{ SEAL }
'-v-I
NAME (PRINT)
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lis::~,t1Po~~ne Herri~~RENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE R~i1AY
(OPTIONAL. SEE REVERSEb 1694
D. SOCIAL SECURITY NUMBER 63-68-
12. RESIDENCE ANY a.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
AND W .
SPECIFY appln~er
o STREET ADDREss15 Nancyaleen Drive
ZIP 12590
o YES"6 NO
;(982
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE?7 13BDATE OF BIRTH 09 ~2
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS WCSD
15. PLACE OF BIRTHPoughkeeosie. Ny
(CITY. STATE / COUNTRY IF NOT USAI
16. FATHER
A. NAME John Joseph Herrin~. Jr.
. B. COUNTRY OF BIRTJ.1 S A
17. MOTHER
A. MAIDEN NAME Karen Stephanie Sullivan
B. COUNTRY OF BIRTHW S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
I impediment exists
22. SIGNATURE OF BRIDE ~
12/2010
by New York Domestic
TIME
MONTH
DAY
YEAR
MONTH
YEAR
AM
03:08PM 07
13
2010
09
10 2010
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B.COUNTY )",tcLesS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY t:. s~ ~ ; 11
31. WITNESS T
NAME (PRINT)
SIGNATURE~