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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST ChristQ~~r Harold~[9~NAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL YI
I
COUNTY Dutchess
CITYfTOWN \Nappinger
~~~~~: 1368 .
~5~1~~~R 78
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
LisaMM~rie McNuJ!~RENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rp.rger
(OPTIONAL - SEE REVERSEb 7 2
D. SOCIAL SECURITY NUMBER 57-72-4 3
12. RESIDENCE A NY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
o STREET ADDREss18 Bowdoin Lane
ZIP 12590
o YES"D NO
)'981
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 086-68-1 R71
2. RESIDENCE A. N'fsTATE) B. ~~ss
C. CHECK ONE 0 CITY Ill! TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 18 Rnwrlnin I ~np. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
M~~ / &17 / ~a19
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A, AGE?R 13B.DATE OF BIRTH 07 /1.2
MONTH DAY
3. A. AGE 31
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Mwr.~n
5. PLACE OF BIRTH Cortlandk NY
(CITY, STATE / C NTRY IF NOT USA)
6. FATHER
14. EMPLOYMENT
A. USUAL OCCUPATION Teaching Assistant
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTHCold Sprina. NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Thomas Gerard McNulty
'B. COUNTRY OF BIRTJ.l S A
17. MOTHER
A. MAIDEN NAME Kathleen Theresa Sibert
B. COUNTRY OF BIRTJJ 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
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Sc:r:
A. NAME Alan Christopher Berger
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME 81 ,~an F~ye WhitF!hill
B. COUNTRY OF BIRTH II 8 A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
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
DEATH
o
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the m n
21. SIGNATURE OF GROOM~
o
o
o
1ST
2ND
3RD
o
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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 only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A, SOLEMNIZATION PERIOD BEGINS
~
{ SEAL}
~
YEAR
MONTH YEAR
NAME (PRINT)
MONTH
07
10
2010
09 07 2010
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT)( Du.7rJfeiS'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY Wl1PfiN(;tRS h4LL~
~ ' r, fJ~/ES(
~/"/I"
, I
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
NAME (PRINT)
SIGNATURE~