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COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT 1368
NUMBER
REGISTER 119
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian Keith Allen
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jenae Rae Bell
~
1 . A. FULL NAME
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
FIRST
..
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 451-79-31 05
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) J. (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN U VILLAGE
~~~CIFY Wappingers Fall
D. STREET ADDRESS 2587 South Ave: Floor 1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r1 YES 0 NO
3. A. AGE 30 3B. DATE OF BIRTH 01 / 14 / 1980
MONTH DAY YEAR
MONTH
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 458-89-1686
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. B. Honolulu
(STAY) (COUNTY)
C. CHECK ONE n CITY 0 TOWN 0 VILLAGE
AND W h'
SPECIFY a lawa
D. STREET ADDRESS BUilding 842 Wright Ave ZIP 19f8o
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
~9 /1980
DAY YEAR
13. A. AGE 29
13B.DATE OF BIRTH
09
....
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4. EMPLOYMENT
A. USUAL OCCUPATION Music Production
B. TYPE OF INDUSTRY OR BUSINESS Music
5. PLACE OF BIRTH Dallas, Texas
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Byron Rena Allen
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joyce Ann Daniels
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
14. EMPLOYMENT
A. USUAL OCCUPATION US Arm>M
B. TYPE OF INDUSTRY OR BUSIN'i'SS ilitary
15. PLACE OF BIRTH KennewicK, Washington
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME David L. Bell
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Barbara A. Marcum
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'QRCE CIVIL AN~ULMENT
DEbTH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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
(3) 0 ANNULMENT
/ /
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
Z
o
Z
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1ST 0 0 1ST
~ 0 0 ~
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is
as to my right to enter into the ~ state.
21. SIGNATURE OF GROOM~ c:::::::--~ 22. SIGNATURE OF BRIDE~
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 !ill 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 ceremon .
24. TOWN OR CITY C ERK 25. A. SOLEMNIZATION PERIOD BEGINS
o 0
o 0
o 0
o 0
I impediment exists
by New York Domestic
~
{ SEAL }
'-v-I
MONTH
YEAR
NAME (PRINT)
YEAR
TIME
MONTH
02
2010
02
28 2011
ZIP
AM
01 :36pM
09
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
l'~VIL
28. PLACE WHERE MARRIAGE OCCURR"
A. STATE NEW YORK B. COUNW<WJ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
:: 't-/l~o{f~
STATE
31. WITNESS T
SIGNATURE~
DOH-98 (09/2009)
NAME (PRINT)
SIGNATURE~