082
"-
N
+
....
z
w
en
w
'"
o
..J
=>
o
:x:
en
z
o
i=
....
a:
tii
a
w
a:
w
(!)
...
a:
a:
...
::;
LL
O.
W
!;;:
(.)
li:
i=
a:
w
(.)
w
a:
w
:x:
~
en
en
w
a:
o
o
...
~
u
w
"-
en
w
C/)
Z
W
0
::i
+
~i:z W
~t:Q
~.... ...
a:"~ c(
I-ffiz
"'..J::; 0
::>ow
::;(!)5 i!
....zen i=
z-
~~~ a:
ff:O(/) w
0....>- 0
w~~
~ffill)
~g~
COUNTY nutchess
CITYfTOWN Wappinger
~~~:~; 1 368
~~;::~~~R 82
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Pet~D~pnnpth f1~R~~~lT SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Patricia Sharon Brilla
MIDDLE CURRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 056- 72 -8593
2. RESIDENCE A. NY B. nllkhp.ss
"\STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWNo,l] VilLAGE
~~~CIFY W~ppingp.rs Falls
0, STREET ADDRESS 81 Carmine Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
01 / ~o /1978
MONTH DAY YEAR
13. A. AGE31
13B.DATE OF BIRTH
02
MONTH
3. A. AGE 32
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS WCSD
15. PLACE OF BIRTHAnnapolis, Md
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Charles Brilla
'B. COUNTRY OF BIRTJJ S A
...
:>
c(
c
wi!
"'u.
~c(
4. EMPLOYMENT
A. USUAL OCCUPATION SE'rvir.p. Arlvisnr
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH Pnuahkeeosie, Nv
(CITY, Si'ATE / COUNTRY IF NOT lfSA)
6. FATHER
A. NAME D~virl I Ollis nP.::In
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ronna Dee Zerrilla
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
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
17. MOTHER
A. MAIDEN NAME Sharon Lucille Hall
B. COUNTRY OF BIRTHU 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
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
II:
W
In
::;
:>
z
"
z
<(
tu
w
II:
Ii;
1ST
2ND
3RD
4TH
I duly swear/affirm, depose
as to my right to enter into the
21. SIGNATURE OF GROOM
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
knowledge and belief that the information I provided is tru
DATE
07/14/2010
by New York Domestic
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to pertorm 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
NAME (PRINT) _ n
~
{ SEAL }
'-v-'
12 2010
YEAR
MONTH
TIME
MONTH
YEAR
DATE 07/14/2010
in ers Falls, NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 ~ELlGIOUS
9 0 OTHER, SPECIFY
SIGNATURE ~
MAILI NG t-~p
20 MI
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
08:34AM 07
PM
15
2010
09
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY f)u t>/,,?~$
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
!;(CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY [(2',1 r::'~ (i /1 (}f('fhll?((:J.~
10 CIVIL
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
SIGNA TU