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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c:1368 '
~5~~~~R 3
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason Nathanial Koskey
MIDDLE CURRENT SURNAME
I
I
STATE FilE NUMBER
(THIS SPACE FOR STA TE USE ONL \1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Emily Irene Scofield
MIDDLE CURRENT SURNAME
-.J
L A. FULL NAME
11, A, FULL NAME
FIRST
FIRST
..
l;j
B. BIRTH NAME, IF DIFFERENT
B, BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C, SURNAME AFTER MARRIAGE Koskey
(OPTIONAL. SEE REVERSE{)95-70-8970
D. SOCIAL SECURITY NUMBER
12. RESIDENCE l"Y B.Queens
(ST~) (COUNTY)
C. CHECK ONE piTY 0 TOWN 0 VilLAGE
~~~CIFYNew orK
D. STREET ADDREss22 /3 Stelnway street APt.
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEh72 66 3162
0, SOCIAL SECURITY NUMBER L. - -
2, RESIDENCE A. NY B. Queens
(STAlE) (COUNTY)
C. CHECK ONE "'IJ CITY 0 TOWN 0 VilLAGE
~~~CIFY New York
0, STREET ADDRESS 2273 Steinway Street Apt. ZIP 111 05
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
03 /17 /1974
MONTH DAY YEAR
111 05
ZIP
~
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
11 )'0
DAY
MONTH
Y)97aO
YEAR
13. A. AGE31
3, A. AGE 35
3B, DATE OF BIRTH
3B. DATE OF BIRTH
4. EMPLOYMENT
A, USUAL OCCUPATION Description Editor
B, TYPE OF INDUSTRY OR BUSINESS Media
5, PLACE OF BIRTH Cleveland. Ohio
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas Lee Koskev
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marv Ellen Lukas
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
14, EMPLOYMENT
A. USUAL OCCUPATIONAccountant
B. TYPE OF INDU~RY OR ijU!l.If\jESSAccountmg
15. PLACE OF BIRTHL;armel, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEDavid Norman Scofield
'B. COUNTRY OF BIRTHU S A
17. MOTHER .
A. MAIDEN NAME Irene Genevlene Rueger
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A~ULMENT
D~TH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,-.- YEAR
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
o
o
o
exists
o
o
o
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say.I~::t to the be
as to my right to enter Into the (r ~_, state.
21. SIGNATURE OF GROOM. '
23. SUBSCRIBED AND SWORN TO/ RMED BEFORE
SIGNATURE OF TOWN OR CI LERK ~
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 only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRIN11 J hn C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE~. DATE 01/25/2010
MAI!.l'iGf.I;IPI)IjE~S 10:59AM 01 26 2010
'-..t-I LU M CCI ush Rd, Wappingers Falls, NY 12590 PM
STREET CITYITOWN STATE ZIP
~~~R~~RTr~~ IO~O~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ...../
SONS NAMED ABOVE ON THE TIME MO DAY Y ROO RELIGIOUS 1 jg CIVIL
DATE AND AT THE TIME AND 111\
PLACE INDICATED. g::.- PM 9 0 OTHER, SPECIFY
MONTH
YEAR
03
26 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY< ~l' /,J.h <S-
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY [))~ tl1 Uff r
29. OFFICIANT
NAME (PRIN11
TITLE ./fI1 t1 r r" ILJ' 8f{}Cf
DATE / fy/.,. /; ()
I I
o
STREET
30. WITNESS TO CEREMONY
NAME (PRIN11 'IT 't~:
SIGNATURE'" Yv, i .
ZIP
~.WnN..'m~
NAME (PRIN11 {It.JD~ wpLjeL5
SIGNATURE~ ..A~~~
S~ej: 1
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