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COUNTY LJUlvlll;;;:>;:>
CITYrrOWN Wappinger
~~~:kc: 1368
~~~I~~~R 179
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael John Russette
MIDDLE CURRENT SURNAME
~
L 0 SUPPLEMENTAL FILE
1. A FULL NAME
FROM THE BRIDE
Linda Patricia O'Reilly
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Hornbeck
c. SURNAME AFTER MARRIAGE Russette
(OPTIONAL. SEE REVERSE)213_92_3424
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
~~~CIFY Wappinger . .
D. STREET ADDRESS 1396 Route 376 Apt#3
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)094 68 7009
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. AR B. Benton
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Bella Vista
D. STREET ADDRESS 5 Sliffer Lane ZIP 72714
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
11 /01 /1968
MONTH DAY YEAR
ZIP 12590
DYES '6 NO
;1'962
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE 46 3B. DATE OF BIRTH 11 /f 3
MONTH DAY
3. A AGE 40
3B. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Airline Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Airline
5. PLACE OF BIRTH Monticello. Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME John William Russette
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Grace Zipp
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 School Bus Driver
B. TYPE OF INDUSTRY OR BUSINESS Transportation
15. PLACE OF BIRTH Poughkeepsie, Ny
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Nelson Kenneth Hornbeck
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Patricia Grace Maitre
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 10 / 09 / 2001
MONT!:V DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? L.J YES 0 NO
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
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
,.
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
1ST 10/09/2001 PouQhkeepsie, Ny ~
~D 0
3RD 0
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23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
DATE
by New York Domestic
t-'-..
{ SEAL }
'-v-'
NAME (PRINT)
YEAR
MONTH
DAY
YEAR
TIME
MONTH
1 0:39AM
PM
2008
02
17 2009
12
20
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON
DATE AND AT THE TI
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCC~ _ . I _.
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND YECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
W~I~'[\t)
NAME (PRINT)
SIGNATURE~
DOH-98 (03f2006)
NAME (PRINT) .
SIGNATURE~