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COUNTY
1tlXfITOWN
DISTRICT
NUMBER
REGISTER
NUMBER
A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
TimothY Owen
FIRST MIDDLE
I
STATI: ~IU: I'IU.~
(THIS SPACE FOR STATE USE ONL Y)
~ ~~.jOV
L 0 SUPPLEMENTAL FILE
Dutchess
Wappinger
1 ':\nR
121
-1
Farley
CURRENT SURNAME
FROM THE BRIDE
Jessica
FIRST MIDDLE
B. BIRTH NAME iMAIDEN NAME), IF DIFFERENT Browne
C SURNAME AFTER MARRIAGE Far 1 e y
(OPTIONAL' SEE REVERSE) 103-66-0872
o SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) ,COUNTY)
C. CHECK ONE [] CITY [] TOWN Xi VILLAGE
MO 11
SPECIFY Wappingers Fa s
D STREET ADDRESS 11 Hillside Avenue
11. A. FULL NAME
Farley
CURRENT SURNAME
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 076-70-2054
D. SOCIAL SECURITY NUMBER
2 RESIDENCEA. New York B Dutchess
[STATE) (COUNTY)
[] CITY 0 TOWN ~ VILLAGE
Wappingers Falls
D STREET ADDRESS 11 Hillside Avenue
C. CHECK ONE
AND
SPECIFY
ZIP 12590
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? X: YES [] NO
13. A. AGE 33 13.B. DATE OF BIRTH Nov. / 26 /1966
MONTH DAY YEAR
3. A. AGE
31
June
MONTH
14. EMPLOYMENT
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
. B. TYPE OF INDUSTRY OR BUSINESS Millbrook Central Schls.
15. PL~CE OF BIRTH (CITY, ST~T~~O~~~~F~ETsUt7' New York
A. USUAL OCCUPATION Assistant Principal
B. TYPE OF INDUSTRY OR BUSINESS Pine Bush Central Schl
5. PLACE OF BIRTH Nanuet , New Yark
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME James Browne
B. COUNTRY OF BIRTH USA
17. MOTHER
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Robert Farley
USA
Mary McElduff
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE First
Grubbs
A. MAIDEN NAME
Patricia
USA
First
(2nd Ceremony)
(2nd Ceremony)
6. NUMBER OF THIS MARRIAGE
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. ,~OW DID LAST MARRIAGE "NO? (3) c::: DIVORCE
C. DATE LAST MARRIAGE ENDED?
31 0 ANNULMENT
/ /
(21 c::: DEATH
B. HOW DID '--"'ST MARRIAGE END? (3) 0 DIVORCE 3\ :: ~NNULME"T 2\ = ~EATH
C. DATE LAST MARRIAGE ENDED? / /'
""AR
YEAR
MONTH )A Y
D ARE ANY FORMER SPOUSE(S) ALIVE? . ~ YES = NO
20. iF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE =OLLOWING ,NFORMATION
DATE OF :ECREE PLACE ISSUED AGAINST WHOM
,MONTH. ~AY. YEAR) 'CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? = YES :] NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATiON
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEARl CiTY. STATEJCOUNTRY. IF NOT USA) SELF SPOUSE
o
1ST
2ND
3RD
4TH
lief that the information I provided is true and that I declare that no legal impediment eXists
I
o
o
\ 22. SIGNATURE OF BRIDE ~
21 SIGNATURE OF GROOM ~
2.7, 2000
Deput:y Town
W
en
z
W
o
:::i
23. SUBSCRIBED AND SWORN TO BEFORt: 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 perto arriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
If checked, this license is to be used only for the pu se of a second or subsequent ceremony.
CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Elaine Town Clerk
\
DATE 7/27/00
NY 12590
9
25
00
25. B. SOLEMNIZATION PERiOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
;-I'-..
{ SEAL }
~
8:45 AM
PM
7
28
00
SIGNATURE
MAILING ADDRE~
PO Box J24,
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. PLACE WHERE MARRIAGE OCCURRED
,r"'
CIVIL
STATE NEW YORK B. COUNTY
rwraff 55
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 "fu'WN OF :J VILLAGE OF
SPECIFY (>0 t/"5Lv tR'~ S; ~
K. t. i r:e;f\
SIGNATURE ~
MAILING ADDRESS
rA n+€R.
STREET
30. WITNESS TO C
/2(001
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
NAME (PRINn
SIGNATURE~
00H-98 (1198)