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~~~:~1368 '
REGISTE~
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Sha\'l!Iifu&nich~E'1 QM~PNT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
--1
1 , A. FUll. NAME
FROM THE BRIDE
Ryan Reid Otterholt
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENfroctor
C. SURNAME AFTER MARRIAG~uinn
(OPTIONAL. SEE REVERS!il,OO 26 2149
D. SOCIAL SECURITY NUMBER 0 - -
12. RESIDENCE NY aQutchess
(ST~TE) (COUNTY)
C. CHECK ONE "'D CITY 0 TOWN 0 VILLAGE
AND C
SPECIf'lL:!eaCon
D. STREET ADDRES~7 Eliza St
11. A. FUll. NAME
FIRST
..
I'l
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl.
D. SOCIAL SECURITY NUMBER l)QR-7?-'?R77
2. RESIDENCE A.NY(STATE) B. ~,?!::
C. CHECK ONE 0 crrv",G TOWN 0 VILLAGE
AND
SPECIFY Do"er
D. STREET ADDREss36A.!1 R nlltp ?2 ZIP 12592
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE8I"b NO
M~H /Q~ /\~IQ
ZIp12508
o YES.....O NO
):977
YEAR
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGh.12 3B. DATE OF BIRTH 12 .%0
MONTH DAY
3. A. AGE30
4. EMPLOYMENT
A. USUAL OCCUPATION Credit Specialist
B. TYPE OF INDUSTRY OR BUSINESS W1pnir.:::l1
5. PLACE OF BIRTHStw.r~n Ct
( , sATE' I COUNTRY IF NOT USA)
6. FATHER
14. EMPLOYMENT
A. USUAL OCCUPATlotAnalyst
B. TYPE OF INDUSTRY OR BUSINESsMedical
15. PLACE OF BIRT..P-hoenix, Az
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMERobert Lee Proctor. Jr.
'B. COUNTRY OF BIRT..\..! S A
17. MOTHER
A. MAIDEN NAME T errv Marlene Reid
B. COUNTRY OF BIRnU S A
1B. NUMBER OF THIS MARRIAGE 2
A. NAME Kelley \^!. Quinn
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Regina M
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
L ,:ohnprt
",'
W
1Il
~
::>
z
Q
!i
Iii
w
~
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DEATH DIVORCE CIVIL ANNULMENT
Q 0 n 1 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 09 L 24 / 2002
MONTH DAY YEAR MON'11!t DAY' -. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? !:J YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY. YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 09/24/2002 Ft. Lauderdale, FI 0 ~
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
f my knlDY1edge and belief that the information I provided is lJand~that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE~ ~ """--
E NAME USE CURRENT NAME
DATE 02/01/2010
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1ST
2ND
3RD
4TH
I duly swear/affirm. deP.Ose and s y
as to my right to enter Into the m r.
U
23. SUBSCRIBED AND SWORN T A IRMED 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.
o If checked. this license Is to be used onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-v-'
YEAR
MONTH
DAY
YEAR
NAME (PRINT)
TIME
MONTH
AM
12:57PM
02
02
2010
04
02 2010
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED AeOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1~;VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~LL it l~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY UJ ..,fJ' ~U ~
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~