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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas Patrick B)(rnes. Jr
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~::oc; 1368 .
~~~I~~~R 95
1 . A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 099 48 2687
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 680 Vassar Rd ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
08 / 04 / 1956
MONTH DAY YEAR
3. A. AGE 53
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Project Manager
B. TYPE OF INDUSTRY OR BUSINESS IBM
5. PLACE OF BIRTH Poughkeepsie, Ny
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas Patrick Byrnes Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ann Clune Dillon
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) d'D1VORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 09/ 05 /
MONTH"", DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? ITYES 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
09/05/1996 Dutchess County, Ny d'
DEATH
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(2) 0 DEATH
1996
YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
11. A. FULLNAME FIRST Den~~~EMarie Fa~~~~TSURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Rumball
c. SURNAME AFTER MARRIAGE B yrnes
(OPTIONAL. SEE REVERSE) 365-64-7780
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 680 Vassar Rd ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
08 /05 /1955
MONTH DAY YEAR
13. A. AGE 54
13B.DATE OF BIRTH
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14. EMPLOYMENT
A. USUAL OCCUPATION Respiratory Therapist
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTH Pontiac, Mi
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Stanley Rumball
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Shirley Ann Carroll
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) d'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12 / 04 / 1997
MONTt:V' DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? U 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 12/04/1997 S1. Charles, Missouri 0 ~
2ND 0 0
3RD 0 0
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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 by New York Domestic
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.
r-I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masterson
{ / 9/2 TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE~ DATE 072 01
'-.,-I MAI~~aedre sh Rd, Wappingers Falls, NY 12590 09:26AM 07 30 2010 09 27 2010
STREET CITYITOWN STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
21. SIGNATURE OF GROO
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DATE
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON,
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHE~NE AND SPECIFY)
~TY OF 9'1'WN OF 0 VILLAGE OF
SPECIFY~""fltC$'i. ~ I ,
NAME (PRINT)
SIGNATURE~