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1. A. FULL NAME
.;;;J I "" I&;;, ur n&;;,vv . unn.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Mic~~~~ Thomas c~~!~ SURNAME
( I HIt; t;PAG/;; I-UH t; I A I/;; Ut;/;; Uf\lL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~~ 1368 .
~5~~J~R 72
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rebecca Lynn Jaworowski
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kellv
(OPTIONAL - SEE REVERSEb02_72_8900
D, SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN~ VILLAGE
~~~CIFYWappin9.ers Falls
D STREET ADDRESl2 Paggl Terrace ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? '1J YES 0 NO
~O ,%979
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)074 60 021 0
D. SOCIAL SECURITY NUMBER --
2. RESIOENCE A NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN..o VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 72 PaQQi Terrace ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? '6 YES 0 NO
08 /15 /1974
MONTH DAY YEAR
12
13. A. AGE29
3. A. AGE 34
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Security Guard
B. TYPE OF INDUSTRY OR BUSINESS Security
5. PLACE OF BIRTH Cortlandt. Nv
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME William Hutchins Kelly
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Alice Mary Cothren
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Office Administration
B. TYPE OF INDUSTRY OR BUSINESS Customer Service
15. PLACE OF BIRTH Littleton , NH
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEJohn Charles Jaworowski
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Roseanne Mary Brasca
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEAJH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'- YEAR
B. HOW DID LAST MARRIAGE END?
(3) 0 ANNULMENT
/ /
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say t
as to my right to enter into the
21. SIGNATURE OF GROOM~
0 0 1ST 0 0
0 0 2ND 0 0
0 0 3RD 0 0
0 4TH 0 0
nd belief that the information I provided is declare that no legal impediment exists
~
USE CURRENT NAME
DATE 07/13/2009
USEC R
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S ate of the bride and groom named abov y any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York Slate. 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) John C. Masterson
{TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~.Ii DATE 07/13/2009
'-v-I MAI~~Gr\RP8a1s ush Rd, Wappingers Falls, NY 12590 12:10~~ 07 14 2009 09 11 2009
STREET CITYITOWN STATE ZIP
~~~R~:RT~~J IO~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
25. B. SOLEMNIZATION PERIOO
ENDS AT MIDNIGHT ON:
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY b\J-h.ktSl
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
DO CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY (oUfU..t.<.f>*-
2.9. OFFICIANT "B V c..'tt- ~ ~'f.\'(
NAME (PRINT) .
SIGNATURE~ ~A~
MAILING ADDRESS II
IS~ At....fk"1 sbf IO-J~J.(t~f'~
STREET CITYfTOWN
30. WITNESS TO CEREM
~
NAME (PRINT)
TITLE
R<.v.
,II8{0,;
DATE
rJY \ 1...'0 I
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ,~
SIGNATURE~