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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JOS~I~O~E Brant Br~~!&~~URNAME
COUNTY Dutchess
CITYfTOWN WappinQer
~~~~~c~ 1368
~5~~J~R 97
1. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 108-78-9205
2. RESIDENCE A. CT B. Litchfield
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY New Milford
D. STREET ADDRESS 18 Nutmeo Drive ZIP 06776
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
3. A. AGE ?? 38. DATE OF BIRTH 12 / 11 / 1987
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Operating Engineer
B. TYPE OF INDUSTRY OR BUSINESS Construction
5 PLACE OF BIRTH Cortlandt. NY
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Charles Henry Bradford
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patricia Dawn Brant
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Emil~ Carroll
MIDDLE CURRENT SURNAME
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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
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bradford
(OPTIONAL - SEE REVERSE) 087 76 9916
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. CT B. Litchfield
(STATE) (COUNTY)
C. CHECK ONE D CITY r! TOWN D VILLAGE
~~~CIFY New Milford
D. STREET ADDRESS 18 Nutmeg Drive ZIP 06776
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES ct NO
/28 /1988
DAY YEAR
13. A. AGE 22
01
MONTH
138. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Medical Billing
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Mount Kisco, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Steven Scott Carroll
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Carolvn Pascento
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(3) D ANNULMENT (2) D DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
D D
D D
D D
D D
diment exists
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DATE
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
r-"-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Joh C. Maste
{TIME MONTH YEAR MONTH
SEAL SIGNATURE~ DATE 07/30/201
'-- -.J MAI~~"'DJ)IR,E~:> AM 07 31 2010 09 28 2010
-v- LU MICOIl ush Rd, Wappingers Falls, NY 12590 02:2Q>M
STREET CITY/TOWN STATE ZIP
~~~R~~~Ri~~~ IO~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR ~ELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 D OTHER, SPECIFY
1ST
2ND
3RD
4TH
I duly swear/affirm. depose and saYJ
as to my right to enter into the mjim!i
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22. SIGNATURE OF BRIDE~
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
D J+cn"
A. STATE NEW YORK B. COUNTY
i2~v~ {'tV" d
Dg-07-IO
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
KCITY OF 0 TOWN OF D VILLAGE OF
I
SIGNATURE ~
SPECIFY