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COUNTY Uutchess
CITYITOWN Wappinger
DISTRICT136tl
NUMBER
REGISTER 3
NUMBER
I _1.1'
(Ins.;) .;:),,..\.;'c rvn ~/1't/J:: VO:>l:: VIVL r;
- I ,." I _ _I
1"_ ..
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jonathan Samuel Kilgore
MIDDLE CURRENT SURNAME
L 0 SUPPLEMENTAL FILE
~
1. A. FULL NAME
FROM THE BRIDE
Jessica Lynn Tetro
FIRST MIDDLE CURRENT SURNAME
B BIRTH NAME (MAIDEN NAME), IF QrFERENT Gielbeda
C. SURNAME AFTER MARRIAGE KI gore
(OPTIONAL -SEE REVERSE)125-76-7202
D. SOCIAL SERi~ NUMBER
12 RESIDENCE A. 8. Dutchess
(STATE).L (COUNTY)
C. CHECK OblE. hkO CITY D TOWN 0 VILLAGE
AND rlS III
SPECIFY 5 Greenhill Drive; Apt 22-c
D. STREET ADDRESS ZIP
FIRST
11. A FULL NAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE>2 06-64- 7 317
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE)..L (COUNTY)
C. CHECK ONE [J CITY U TOWN 0 VILLAGE
~~~CIFY Fishklll
D STREET ADDRESS 5 Greenhill urlve; Apt ~~-e ZIP 1 ~o~4
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE? 0 YEt98~O
AGE 26 3B. DATE OF BIRTH 12 )14 ~
MONTH DAY YEAR
12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1] NO
04 /17 /1978
DAY YEAR
3. A. AGE 30
3B. DATE OF BIRTH
13. A.
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Field Service
B. TYPE OF INDUSTRY OR BUSINESS Semiconductor
5. PLACE OF BIRTH Lancaster, Pa
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Kenneth W. Kilgore
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Emily B. Flory
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 Student
ue(;
B. TYPE OF INDUBRY OR BUSI~SS
15. PLACE OF BIRTH ueens, y
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Gordon C. Tetro
'B. COUNTRY OF BIRTHU S A
17. MOTHER C I' G' Ib d
A. MAIDEN NAME hrysta Ie A. lee a
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL AN~ULMENT
DEATH
o
DE6TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
f my knowledge and belief that the information I provided is true and that I declare that no I
C
22. SIGNATURE OF BRID~
o 0
o 0
o 0
o 0
al impediment exists
23. SUBSCRIBED AND SWORN TO/AFFI MED BEFORE E
SIGNATURE OF TOWN OR CITY CL RK ~
This license authorizes the marriage in New k 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, 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) J hn C. Masterson
{TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~, DATE 01/23/2009
"-v-' MAI~~G~F~m bush Rd, Wappingers Falls, NY 12590 01 :40~~ 01 24 2009 03 24 2009
STREET CITYrrOWN STATE ZIP
~~~~~~RT~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~~ Ie., HvJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF 0 TOWN OF [1;(\tILLAGE OF
SPECIFY tIIJ4.;oPJ;J{11-KA ~
CIVIL
r7z:rtCU
~v-/
J
MONY ,}
tl crJ/ tv. K./ Lt; ~ E..
NAME (PRINT)
SIGNATURE~ ..