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COUNTY Dutchess
CITYffOW{: Wappinger
DISTRICT 365 .
NUMBER
REGISTER 135
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert William Keil
I
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
~
L D SUPPLEMENTAL FILE
1 . A. FUll. NAME
FROM THE BRIDE
Pamela Ann Flamholtz
MJgPLE CURRENT SURNAME
I ownsend
B. BIRTH NAME (MAIDEN NAME)'F<e'rrERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEU55- (U-Ujb~
D. SOCIAL SI;.CURJTY NUMBER D to..
NY UIClless
12. RESIDENCE A. B.
(STATE).t. (COUNlY)
C. CHECK Q~. D CITY 0 TOWN 0 VILLAGE
AND vvappmger
SPECIFY 52 Osbome Hill Rd, LuL 33 12590
D. STREET ADDRESS ZIP ""
E. IS RE~~NCE WITHIN LIMITS OF CITY OR INCORPORA"B'9VIll.AGE? 1-8 0 Y~~d'O
13. A. AGE 3B. DATE OF BIRTH L.... E
MONTH DAY YEAR
11. A. FUll. NAME
MIDDLE
CURRENT SURNAME
FIRST
0-
N
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE{)73-54-5965
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE).L. (COUNTY)
C. CHECK ONW 0 CITY LJ TOWN 0 VILLAGE
AND .
SPECIFY applnger
D. STREET ADDRESS b2 USborne Hili Ka, Lot 33 ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? eP
3. A. AGE 39 3B. DATE OF BiRTH 08 / 1
MONTH DAY
'12590
'"
Y/f9'~
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Machinist
B. TYPE OF INDU,SIt1Y,OR IU.!~IN,ESS Metro North Kall Koaa
5. PLACE OF BIRTH vvnlte t-"Ialns, Ny
14. EMPLOYMENT
Home Maker
A. USUAL OCCUPATION Home Maker
B. TYPE OF INDlJlijTRY OR BUS~:;;S
tjeacon I"'JY
15. PLACE OF BIRTH '
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER W'II' T d
I lam ownsen
A. NAME USA
B. COUNTRY OF BIRTH
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert Ernst Keil
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ethel Florence Van Dorn
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 2
17. MOTHER P t" M R b'
a nCla ary 0 Inson
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 2
18. NUMBER OF THIS MARRIAGE
9. ~Rij~l?~EV~FR~h~<t~8us MARRIAGES WHICH ENDED BY
DIV1RCE CIVIL AN~ULMENT
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ~~ULMENT 1 ~9(fEATI1
C. DATE LAST MARRIAGE ENDED? 03 / /
MONT"" DAY
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, YEA!!.> (CITYICOI,INTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 06/26/199u Phoemx, Arizona r'5
2ND 0
3RD 0
4TH
I duly swear/affirm, depose and say, that t the
as to my right to enter into the ma ate.
21. SIGNATURE OF GROOM ~ '
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE {IF TOWN OR CITY CLERK ~ ~
This license authorizes the marriage in NewY rk 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, 1his license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR Cll'( Cl-ERKC M t 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn , as erson
{SEAL SIGNATURE ~ DATE 12/08/2009 TIME MONTH YEAR MONTH
\--J MAI~ItlfPd8i~ appingers Falls, NY 12590 AM 12 09 2009 02 06 2010
-v- 03:12pM
STREET ClTYrrOWN STATE ZIP
~~~R~~R;~~~ ~~O~~N~~f. 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. Y YEAR 0 $- RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND AM
PLACE INDICATED. fJ' C/O PM 9 0 OTHER, SPECIFY
~~tJm~~ 1!;' : ~f.t;-f<.. TITLE flt51 aIC/
SIGNATURE~ ~ DATE f)~/{> ;;uJ09
MAILING ADDRESS / c;. ./ _.1 "V','"' c-;->t2
~I V I {)t.. p. ( ()/2..8 vA-!..OV IV f /'oU t/ U
STREET CITYffOWN STATE ZIP
30. WITNESS TO CEREMONY 31. WITNE~SEREMONY _
NAME (PRINT) 71< Q ( Q.. NAME (P.Bl!' -:::::::==:::-1l1 <: ? ,,-
SIGNATURE~ SIGNATURE ...
DeoTH
19. ~~~~l?~~R~FR~h~'tT8us MARRIAGES WHICH ENDED BY
DI~ORCE CIVIL A~ULMENT
""
B. HOW DID LAST MARRIAGE END? (3) 0 DIVO'ff2 (3) ~ULMENT 2dbij! DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTIIII' DAY' ".- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
to
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
~27l1:fl2o(f'~) pd1Jg/W~~ep~~Lf{J~,^, 'fc,uff<> S~F SPOUSE
1ST 0 0
2ND 0 0
3RD 0 0
o 0
legal impediment exists
DIfj TH
YEAR
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY bJrclf~:;5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
j& CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY f3 6A-ctJ AJ
t~~~