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COUNTY Dutchess
CITYfTOWN '^'appinger
~~~:~c; 1 368
~~~I:J~R 146
~ I A I I:. U.- NI:.W YUHK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
s~R>U Rolf OIS~~RENT SURNAME
FIRST
(TH/S SPACE FOR STA TE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
DarlenE'DL~\If:~IYIl Rr16J~Rt& SURNAME
~
1 . A. FUU NAME
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENTKent
C. SY~~~~N~~~~~t~~~~~sQlsen
D. SOCIAL SECURITY NUMBER 1 ?9-6?-0303
12. RESIDENCE A.NY B,[)lltchp!=:!=:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY oZJ TOWN 0 VILLAGE
AND W .
SPECIFY ~rrlngAr
D. STREET ADDRESs41 Losee Road
ZIP 12590
DYES..o NO
,,{QR6
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 00-60-9611
2 RESIDENCE A. N'(STATE) B. q~~~~ss
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \AI .
SPECIFY .. iilppmger
D. STREET ADDRESS 41 Losee Rn~rl ZIP 1 ?fl90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES""~ NO
Mot1 / ~1 / ~aP6
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE42 3B. DATE OF BIRTH OQ "Q'1
M'5NTH DAY
3. A. AGE41
4. EMPLOYMENT
38. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATIONHnmpm~kpr
B. TYPE OF INDUSTRY OR BUSINESS Homemaker
15. PLACE OF BIRTHSnI Ithamntnn Nv
(CITY. STATE / COUNTRY IF Ndf USA)
16. FATHER
A. NAMEAIIOIIc::t P::l111 Rnllkpr
. B. COUNTRY OF BIRTf'U S A
17. MOTHER
A. MAIDEN NAME K~thleen Eliza Kent
B. COUNTRY OF BIRTf-A J S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
....
:;:
<C
A. USUAL OCCUPATION Carpimters Union
B. TYPE OF INDUSTRY OR BUSINESS Constn Iction
5. PLACE OF BIRTH ~1~.~T~1fi'C~~RY IF NOT USA)
6. FATHER
A NAME Rolf Olsen
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Irene Ringman
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) r!'f DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 01 /?9 / /008
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? Ili'!'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. STATE/COUNTRY. IF NOT USA) SELF SPOUSE (MONTH. DAY. YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 01/?9/?008 Mineola, Ny 1!"1
2ND 0 0 2ND 0
3RD 0 0 3RD 0
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is
as to my right to enter into the marriage state.
~
21. SIGNATURE OF GROOM~
w
en
z
w
(,)
::::i
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk 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
DATE
09/25/2008
by New York Domestic
~
{ SEAL}
'-.t-'
NAME (PRINT)
MONTH
MONTH
YEAR
TIME
YEAR
09/?5/?OOR
11 :09AM 09
PM
26
2008
11
24 2008
ZIP
STATE
27. TYPE OF CEREMONY
o [1..1fELlGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF rn--fOWN OF 0 VILLAGE OF
SPECIFY Ii' P 111 .f.7STe-4cL
tI
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
It) A SSJ!! J(
10 CIVIL
A. STATE NEW YORK B. COUNTY