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STATE O~,,'NEW.~JYORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian D.
C 1ST
C 2ND
C 3RD
u C 4TH
wledge and belief that the information I provided is true and that I declare that no legal impediment exists
. SIGNATURE OF BRIDE ~ ~.9~~ U~) ~Lr$l ' 4- .
23. SUBSCRIBED AND SWORN TO BEFORE ME ....... De ut Town Cle~ ~DATE ~11J. /Y'\
SIGNATURE OF TOWN OR CITY CLERK ~ -- ::r-u-;
This license authorizes the marriage in New York 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.
o 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) ~Elaine H. Snowden. Town Clerk
{SEAL SIGNATURE~(~tluJ.O~~LI..JhI.AII DATE 4/14/00 TIME MONTH
MAILING ADDRESS AM 04
'-.r-I PO Box 324. Wappingers Falls. NY 12590 12: 15 PM
STREET ITYITOWN STATE ZIP
[ CERTIFY THAT [ SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY -v::::
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIM Me DAY YEAR RELIGIOUS 1 _ (;;VIL
DATE AND AT THE TIME AND
PLACE IND
COUNTY
,
Dutchess
Wappinger
1168
37
~OWN
DISTRICT
NUMBER
REGISTER
NUMBER
L A FULL NAME
Conners
FIRST
MIODlE
CURRENT SURNAME
a.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 087-66-3243
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B Dutchess
(STATE) [COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS Rt. 9D P.O. Box 432
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 30 3B. DATE OF BIRTH Feb. /
MONTH
ZIP 12537
DYES~NO
12 /1970
YEAR
4. EMPLOYMENT
DAY
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A. USUAL OCCUPATION Auto Body Technician
B. TYPE OF INDUSTRY OR BUSINESS Jimmv's Auto Recondit
5. PLACEOFBIRTH Poughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
Gerald Conners
USA
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
Evelyn Marino
USA
First
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (3) L DIVORCE
C. DATE LAST MARRIAGE ENDED?
,.3) C ANNULMENT
/ /
(2) 0 DEATH
1ST
2ND
3RD
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r
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
/~111/c()
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Kelly R.
FIRST MIDDLE
.-J
Myrick
CURRENT SURNAME
11. A. FULL NAME
B. BIRTH NAME \MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Conner.s
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE.\. Npt.T York
[STATE)
C. CHECK ONE 0 CITY ~
AND
SPECIFY 'f.J"'pp;ngpr
D. STREET ADDRESS Rt. 9D P.O. Box 432 ZIP 12537
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/08 /1975
DAY YEAR
078-80-1..80R
B. ~utchess
TOWN 0 VILLAGE ( OUNTY)
13. A. AGE
?4
13.B. DATE OF BIRTH Oct.
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Cus tamer Service Rep.
on B. TYPE OF INDUSTRY OR BUSINESS unemployed
15. PLACE OF BIRTH T.:lV:ll J 011ebec Canada
(CITY. STATEfCOUNTRY'iF NOT USA)
16. FATHER
A. NAME Jerry Myrick
B. COUNTRY OF BIRTH TT~A
17. MOTHER
A.MAIDENNAME F.lisp- Rp-langer
B. COUNTRY OF BIRTH Canada
1 B. NUMBER OF THIS MARRIAGE Fir s t
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID ,--1ST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST \lARRIAGE ENDED?
(3) L ANNULMENT
/ /
121 L DEATH
MONTH DA Y YEAR
D. ARE ANY =ORMER SPOUSE(Sl ALIVE? 0 YES = NO
20. IF PREVIOUS~Y DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE (;F :ECREE PLACE ISSUED AGAINST WHOM
iMONTH. JAY. YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
YEAR
00
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNrO~~
C. LOCATION OF CEREMONY (y
(CHECK ONE AND CIFY)
c.,; VILLAGE OF
It..