122
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian J. Robinson
FIRST MIDDLE CURRENT SURNAME
I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE ONL Y)
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DISTRICT
NUMBER
REGISTER
NUMBER
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Wappinger
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B. BIRTH NAME, IF DIFFERENT
FROM THE BRIDE
11. A. FULL NAME Patricia A. King
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Cooper
Robinson
129-56-4746
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 126 -6 2 -4 3 3 6
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A New York
(STATE)
C. CHECK ONE c:: CITY :j{roWN .~
AND W.
SPECIFY app~nger
o STREET ADDRESS 55 Robert Lane ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE' . 0 YES ~ NO
/10 /1963
DAY YEAR
v. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
J. SOCIAL SECURITY NUMBER
12. i'lESIDENCEA. New York
(STATE)
v. CHECK ONE 0 CITY:lEJ TOWN 0
~~~CIFY Poughkeepsie
J STREET ADDRESS 46 Laffin Lane ZIP 12603
_. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' 0 YE~ NO
/25 /1970
DAY YEAR
B Dutchess
(COUNTY)
VILLAGE
B Dutchess
I COUNTYI
VILLAGE
29
3. A. AGE
37
3B. DATE OF BIRTH
13.B. DATE OF BIRTH
Dec.
MONTH
May
MONTH
13. A. AGE
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION
Homemaker
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A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Foam & Wash Mobil
5. PLACE OF BIRTH Poughkeepsie N~w Yurk
(CITY. STATE/COUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Poughkeepsie New York
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME
16. FATHER
A. NAME
Charles H. Cooper Sr.
USA
John
J. Robinson
USA
B. COUNTRY OF BIRTH
B. COUNTRY OF BIRTH
7. MOTHER
17. MOTHER
A. MAIDEN NAME Patricia A. Scutt
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE Second
19. PREVIOUS MARRIAGES
~. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
DEATH
A. MAIDEN NAME
J. Dornath
Phyllis
USA
8. NUMBER OF THIS MARRIAGE Third
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
Two
DEATH
B ~W DID LAST MARRIAGE END' (3?t DIVORCE ,3\ _ ANNUL',1ENT ,21 c:: DEATH
:. DATE LAST MARRIAGE ENDED? 0 ct. /26 /1998
MONTH JAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES = NO
'F PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
MONTH. DAY. YEAR) (CITY, STATE/COUNTRY. IF NOT USA, SELF SPOUSE
10/26/98 Poughkeepsie. New York c:: x-
B. HOW DID LAST MARRIAGE ;:ND' :3~ DIVORCE ,3\ 0 ANNULMENT 12) 0 DEATH
C. DATE LAST MARRIAGE ENDED? Dec. / 05 ./1989
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSEiS) ALIVE? ~ YES ::: NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION 20.
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR\ CITY. STATE. COUNTRY. IF NOT USA) SELF SPOUSE
1ST 10/1/86 Dutchess Co. New York ~ 1ST
2ND 12/5/89 Dutchess Co. New York ~ 2ND
3RD ~ 3RD
4TH 0 4TH .J
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the Information I provided is true and that I declare that no 1P,{j'" i~iment exists
as to my right to enter into the . ge state. __ _..:----:- .
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF - "'" '
'--.J
Deputy Town Clerk
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23. SUBSCRIBED AND SWORN TO 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 perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
If checked. this license is to be used only for the purpose of a second or subsequent ceremony,
CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Elaine Town Clerk
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
~
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
7/27/00
12590
DATE
NY
SIGNATURE
M"J.t~G~~~E'24 ,
s T
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON T1HE
DA TIE AND AT THE TIME AND
PLACE INDICA
AM
1 : 30 PM
28
00
09
25
00
07
ZIP
2B. PLACE WHERE MARRIAGE OCCURRED
1~
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY l
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF VILLAG~ M.
SPECIFY f,I)~ ~,.
NAME (PRINT)
SIGNATURE ~
OOH-9B (1198)