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COUNTY nlltr:hp~~
CITY/TOWN W::Ippingpr
~~~:~: 1 ~RR
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
D9Xdt2EEdrnllnd tt~l~NT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
-.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ann Julia McErleane
MIDDLE CURRENT SURNAME
1. A. FUll NAME
11. A. FULL NAME
FIRST
FIRST
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N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE\. 25-62-4535
D. SOCIAL SECURITY NUMBER .1
12. RESIDENCE ANY BPutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN~ VILLAGE
~~~CIFYWappinqers Falls
D STREET ADDRES~22 Sterling Drive
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 n4-7? -951 9
2. RESIDENCE A. NY B. ()lltr:hp~~
lSTATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWNIl] VILLAGE
~~~CIFY WClppin(]pr~ F::III~
D. STREET ADDRESS 622 Sterling Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 38 3B. DATE OF BIRTH nQ / 1 n /1971
MO~-?I; DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE35 13B.DATE OF BIRTH 09 )t'1
MONTH DAY
ZIP 12590
~D YES 0 NO
j974
YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION PersonClI R::mkpr
B. TYPE OF INDUSTRY OR BUSINESS Citibank
5. PLACE OF BIRTH F ::Iirf::lX, Viraini::l
(CITY, STATE / COUN'ffiY IF NOT USA)
6. FATHER
A. NAME Donald EdrTl1 inri Hill
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME M::Iry Eliz::Ibeth Danzi
B. COUNTRY OF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT ;
o n
14. EMPLOYMENT
A. USUAL OCCUPATloNSUrqical Physician Assistant
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTHNyack, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Dennis Francis McErleane
'B. COUNTRY OF BIRTJ.l S A
17. MOTHER
A. MAIDEN NAME Joann Helbig
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
MONTH OA Y 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
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that
as to my right to enter into the marriage
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 ~D 0 0
o 0 3RD 0 0
o 0 4TH 0 0
knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
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USE cu
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 911 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
NAME (PRINT) Jo
MONTH
:Iu-r--
DATE 07/13/2010
by New York Domestic
~
{ SEAL }
'-v-'
YEAR
YEAR
TIME
MONTH
SIGNATURE ~
MAILING ADDRESS
20 Middleb
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
11 : 13AM
PM
07
14
2010
09
11 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~'TY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~"\Lv
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
NAME (PRINT)
SIGNATURE~
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