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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~; 1368
~5~I:J~R 57
~ I A leUI- NeW YUHK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Keith Jason Perri
MIDDLE CURRENT SURNAME
(THIS SPACE FOR STATE USE ONLY)
-.J
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
FROM THE BRIDE
Kim Anne Bennett
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT G ra u
C. SURNAME AFTER MARRIAGE Perri
(OPTIONAL. SEE REVERSE096_62_6957
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESs37 Losee Koad
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)073_66_7248
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wap~inger
D. STREET ADDRESS 37 Losee Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"fJ NO
01 / 16 /1971
DAY YEAR
ZIP 12b90
DYES "fJ NO
;t971
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE37 3B. DATE OF BIRTH 12 ))1
MONTH DAY
3. A. AGE 38
3B. DATE OF BIRTH
MONTH
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wi!
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c:(
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS Local 3 I BEW
5. PLACE OF BIRTH Cortlandt, NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Richard Joseph Perri
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Eva Marie Lescher
B. COUNTRY OF BIRTH USA
6. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATION Office Manager
B. TYPE OF INDU~TRY OR BUSI~i..S$ Child Care
15. PLACE OF BIRTH \.lUeens, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
,A. NAME John Geor~e Grau, Jr.
B. COUNTRY OF BIRTHU A
17. MOTHER
A. MAIDEN NAME Annette Caiazza
B. COUNTRY OF BIRTHU S A
L.
16. NUMBER OF THIS MARRIAGE
u
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANOULMENT DEaTH DI1'ORCE CIVIL A~ULMENT D'Q'TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) D. DEATH B. HOW DID LAST MARRIAGE END? (3) [j DIVORCE (3) ~ANNULMENT (B~ DEATH
c. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 07 / 1 / 20
MONTH DAY YEAR MONTI;Ioo" DAY, . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE ~ONTH, OilY, YEAR) (CITY/COUN1)< STATElCOUNlf\Y, IF NOT USA) SELF SPOUSE
o 0 1ST u7/31/2006 Putnam l;ounty, New 0 ~
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
my knowledge and belief that the information I provided is true and thal'l declare that no legal impediment exists
22. SIGNATURE OF BRIDE~ --1",1 IY7 O. &/7 ~
~ USE CURRENT NAME
DATE 06/26/2009
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say' th
as to my right to enter into the m la
21. SIGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN TO/ FIRM BEFORE M
SIGNATURE OF TOWN OR CI CLER ~
This license authorizes the marriage in Ne ork 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 purpo.se of a second or subsequent ceremony.
~ 24. TOWN OR CiTy C!-ERKC M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn . asterson
{SEAL SIGNATURE ~ _ DATE 06/26/2009 TIME MONTH DAY YEAR
"-v-' MA~tf~a~ ush Rd, Wappingers Falls, NY 12590 01 :08 ~~ 06 27 2009
STREET CITYIfOWN STATE ZIP
~~~R~~RT~~J lo~O~~~N~Zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 'blRELIGIOUS
DATE AND AT THE TIME AND AM f -
PLACE INDICATED. 11,')0 m 9 0 OTHER, SPECIFY
by New York Domestic
MONTH
YEAR
08
25 2009
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED . I..
A. STATE NEW YORK B. COUNTY D/JfCAlrS~
-
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
$i( CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY pou ~vd(ee p, i e
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)