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COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~CRT 1368
~~~~~~R 158
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kenneth Whitlock
MIDDLE CURRENT SURNAME
STATE I'IL.E NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tish Evans
MIDDLE
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
CURRENT SURNAME
"-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Whitlock
(OPTIONAL - SEE REVERSEl093_52_1724
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D STREET ADDREss54 Jackman Drive; Apt B
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 147-60-0800
2 RESIDENCE A NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 54 Jackman Drive; Apt B ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
10 /21 /1959
MONTH DAY YEAR
ZIP 12603
DYES '6 NO
;t'963
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE45 3B. DATE OF BIRTH 07 Al6
MONTH DAY
3. A. AGE 48
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Retail Manager
B. TYPE OF INDUSTRY OR BUSINESS Retail
5. PLACE OF BIRTH Orange. NJ
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Oscar Alfonso Whitlock
B. COUNTRY OF BIRTH USA
7_ MOTHER
A. MAIDEN NAME Dorothy Louise Germaine
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION SurQical Technician
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Valhalla, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Unknown
'B. COUNTRY OF BIRTHUnknown
17. MOTHER
A. MAIDEN NAME Rosemary Evans
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
B. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) t1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 07 / 30 / 2008 '
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? &'YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20.
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
07/30/2008 Long Branch. NJ
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
,.
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say,
as to my right to enter into t~e !liar
21. SIGNATURE OF GROOM ~
~
o 1ST 0 0
o 0 ~D 0 0
o 0 3RD 0 0
o 0 4TH 0 D
ge a d belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ . f, J j) ~~
~CURRENTNAME
DATE 10/10/2008
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New Drk State of the bride and groom named above by any person authorized
Relations Law !ill 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
SEAL SIGNATURE.' DATE
MAILING .A~PRE,9 AM 1 0
'-v-.l 20 IVlldOl 03: 17 PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE ANO AT THE TIME AND
PLACE INDICATED.
by New York Domestic
MONTH
YEAR
11
2008
12
09 2008
1~IL
28. PLACE WHERE MARRIAGE OC~~
A. STATE NEW YORK B. COUNTY k iZHtIJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
D CITY OF 0 TOWN OF ~LLAGE ~. JI
SPECIFY W~I'II~ ~
31.
NAME (PRINT)
SIGNATURE.
DOH-B8 (0312006)
NAME (PRINT)
SIGNATURE.