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1 . A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Antl1o~oba\Mrence b~~[MI;I.ttME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~: 1368
~~~li~~R 140
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
ni~M~L~FmAA VP~ENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 4.R4.-11-R4.67
2 RESIDENCE A. N;t,:ATEI B. gold~~ess
c. CHECK ONE D CITY!iI' TOWN D VILLAGE
~~~CIFY Fi~hkill
D STREET ADDRESS 5R T ownview Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES r!f NO
3. A. AGE 37 3B. DATE OF BIRTH MON9~ / o~O / y~~73
4. EMPLOYMENT
A. USUAL OCCUPATION Army
B. TYPE OF INDUSTRY OR BUSINESS Milit::lry
5. PLACE OF BIRTH (~n~~~E ~~~'rR~~~~ USA)
6. FATHER
A. NAME Lawrence Frank L~ Br1lne
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME RnnniA SIJA .IAnkin~
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIALSECURITYNUMBER 067-72-3493
12. RESIDENCE A. t-JV B. nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 58 Townview Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!f NO
nFi /?~ Aq7fi
MONTH DAY YEAR
13. A. AGE 35
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION P::lyrnll ClArk
B. TYPE OF INDUSTRY OR BUSINESS Health Quest
15. PLACE OF BIRTH Manhattan, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME l=r1w::!rrl ~AnrgA VAg::!
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mary Theresa Schiera
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
n 0
DEATH
o
DEATH
n
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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
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
0:
W
CD
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II:
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, t to the b
as to my right to enter into the marr e st
21. SIGNATURE OF GROOM~
.-
23. SUBSCRIBED AND SWORN TO/AFFI ED BE
SIGNATURE OF TOWN OR CITY CLER
D D 1ST D D
D D 2ND D D
D D ~D D D
D D 4TH D D
of my knowledge and belief that the information I provided is tr7Jnd that I declare that no legal impediment exists
22.SIGNATUREOFBRIDE~ ~L~ \JQm /
USE CURRENT NAt) ;----
DATE 10/07/2010
by New York Domestic
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.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) John C. Mast
\...
~
{ SEAL }
"-v-I
MONTH
YEAR
YEAR
TIME
MONTH
DATE 10/07/201
h Rd. Wa~~~i;rs Falls5T~EY 12592,
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 D RELIGIOUS
9 D OTHER, SPECIFY
SIGNATURE ~
MAILING ADDRESS
20 Middleb
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
05 2011
10
08
2010
04
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~'l'l..~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./'
D CITY OF 0 TOWN OF ltl'\tILLAGE O~ ~ 1/
SPECIFY W ~AJ&t4s ~