077
+
I-
Z
W
(/)
W
'"
Cl
...J
:>
0
J:
(/)
Z'
0
~
a:
!i;
a
w
a:
w
"
0(
ii:
a:
0(
::;
u.
0
w
:c
()
u:
>=
a:
w
()
w
a:
w
J:
~
(/)
(/)
w
a:
Cl
Cl
0(
~
(3
w
a.
(/)
w
en
z
w
0
::::i
+
Z' .
a:J:Z W
~!::Q
~I- ~
a:"';S
~~~ 0
:>()W
::;,,5 u:
~~CJ) i=
~~~ a:
u:-
\SO(/) W
1-> 0
w~~
Sffi",
z!53;
a.
N
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~; 1368 .
~5~~;~R 77
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bri~Df;ancis HY!~~T SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kristine Anne Richardson
MIDDLE CURRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hyland
(OPTIONAL - SEE REVERSE~ 1
D. SOCIAL SECURITY NUMBER u55-66-40 9
12. RESIDENCE ANY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN\(] VILLAGE
~~~CIFYWappingers Falls
D. STREET ADDREss120 Market St; Apt 3 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
~3 A978
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 130-74-426R
2. RESIDENCE A. N"YsTATE) B. qr~~e
C. CHECK ONE 0 CITY J[I TOWN 0 VILLAGE
AND
SPECIFY Crawford
o STREET ADDRESS 28?~ Rnlltp. 5? ZIP 12566
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES\(] NO
M~ / Q.~ / ~E~J30
13B.DATE OF BIRTH
05
MONTH
13. A. AGE~?
3. A AGE 30
4. EMPLOYMENT
A USUAL OCCUPATION Director Of Sales
B. TYPE OF INDUSTRY OR BUSINESS Hiltnn Hntp.l~
5. PLACE OF BIRTH Manhattan NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Wappingers Central
15. PLACE OF BIRTH Poughkeepsie. NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEJohn Andrew Richardson
'B. COUNTRY OF BIRTJJ S A
A. NAME Richard John Hyland
B. COUNTRY OF BIRTH Fnol~nrl
7. MOTHER
A. MAIDEN NAME Marjorie Fr~nr.p.~ ~r.hwp.izer
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
17. MOTHER
A. MAIDEN NAME Joanne Lena Potenza
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
(2) 0 DEATH
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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) ICITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose a
as to my right to enter i
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
o t e est of my knowledge and belief that the information I provided is true
ge stat.
~
o 0
o 0
o 0
o 0
hat no legal impediment exists
USE C
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
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 perlorm 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
by New York Domestic
~
{ SEAL }
'-.t-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DATE 07/08/2010
in ers Falls NY 12590
ITYIT WN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 ~ RELIGIOUS
'2 ~ (Ii' (:)'7 /0 90 OTHER, SPECIFY
11 :28AM 07
PM
09
2010
09
06 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.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 'bvtc.he~
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF
10 CIVIL
TITLE
<<?c. rkh~V
/I :/ -/~
SPECIFY
l.e
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
NAME (PRINT)
SIGNATURE~