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1. A FUll NAME
STATE OF NEWVOR~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bruce James
FIRST MIDDLE
I STATE FILE HUMBER I
(THIS SPACE FOR STATE USE ONL Y)
/ 111/~)eU
Lo SUPPLEMENTAL FILE -.l
Dutchess
Wappinger
1368
186
FROM THE BRIDE
Denise Margot
FIRST MIDDLE
Wilson
CURRENT SURNAME
Ferrier
CURRENT SURNAME
11. A. FULL NAME
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIAl SECURITY NUMBER
12. RESIDENCEA. New York
(STATE)
o CITY 00 TOWN D
Wappinger
D STREET ADDRESS 4 Pine Hill Drive
ZIP 12590
053-72-0092
Ferrier
076-66-5515
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SDCIAl SECURITY NUMBER
2 RESIDENCE A Connecticut B. Fairfield
(STATE, (COUNTY)
C CITY ~ TOWN 0 VilLAGE
Greenwich
27 Harrold Avenue
Dutchess
(COUNTY)
VilLAGE
B.
C. CHECK ONE
AND
SPECIFY
C. CHECK ONE
AND
SPECIFY
3. A. AGE
29
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE" 0 YES 00 NO
13. A. AGE 30 13.B. DATE OF BIRTH J an. / 15 /1970
MONTH DAY YEAR
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Occupational Therapist
B. TYPE OF INDUSTRY OR BUSINESS Rehab Programs. Inc.
15. PLACE OF BIRTH Poughkeepsie. New York
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Courter
B. TYPE OF INDUSTRY OR BUSINESS Federal Express
5. PLACE OF BIRTH Yonkers. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Margot T. Leyendecker
USA
First
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Bruce Paul Ferrier
USA
Paul S. Wilson
USA
Patricia Ann Russell
USA
B. NUMBER OF THIS MARRIAGE
First
1 B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE' CIVil ANNULMENT
DEATH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END" '31 [] DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) D DE.~TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
.31 == ANNULMENT
/ /
(2\ 0 DEATH
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? eYES == NO
20. iF PREVIOUSLY DIVORCED OR ANNUlED. PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
,MONTH. DAY, YEAR) (CITY, STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? eYES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEiCOUNTRY, IF NOT USA) SELF SPOUSE
o
1ST
2ND
3RD
4TH
I. being duly sworn, depose and say
as to my right to enter into the mar'
21. SIGNATURE OF GROOM ~
o
o
o
;-
Deputy Town
DATESept. 27. 2000
by New York Domestic
W
en
z
W
o
:J
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized
Relations Law ~llto perform marriage ceremonies within ew 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 Dr subsequent ceremony.
24. TOWN OR CITY cLERElaine Town Clerk 25. A. SOLEMNIZATION PERIOD BEGINS
MONTH
DAY
YEAR
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
~
TIME
MONTH
DAY
YEAR
DATE 9/27/00
NY 12590
8 : 30 AM
PM
26
00
9
28
00
11
Wappingers Falls,
CITYfTOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
2PM ~~ 11
STATE
27. TYPE OF CEREMONY
o XJl{RELlGIOUS
9 0 OTHER. SPECIFY
ZIP
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Dutchess
c. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
XJ{CITY OF 0 TOWN OF == VilLAGE OF
SPECIFY Poughkeepsie
1 == CIVil
29. OFFICIANT D . 1 B W d
NAME (PRINT) anl.e . ar ~
SIGNATURE~~~~
MAILING ADD A
St. John's Lutheran 55 Wilbur Blvd.
STREET CITYITOWN
30. WITNESS TO CEREMONY
Jam
/
Pastor
TITLE
11-12-00
DATE
Poughkeepsie, NY
STATE
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
SIGNATURE ~