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CITYfTow~Nappinger
~~~~~CT 368 .
~~~I~J~ 32
""."...~. ........ .~.I.'
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Da"MiJDdOseph CI8'U~~ENT SURNAME
f,n/~ ':>r"<"1vc run .:J'IiIC VUe:. UI'<IL.'I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Christine Kelp
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl
D SOCIAL SECURITY NUMBER 1J5!=i-6?-R70~
2. RESIDENCE A NY(STATE) B. DI~!ru~~~
C. CHECK ONE ....0 CITY 0 TOWN 0 VILLAGE
AND .
SPECIFY POIlghkeerslp.
D. STREET ADDRESs1 ~ North Randolph Ave. ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ..0 YES 0 NO
3. A. AGEJO 3B. DATE OF BIRTH 1 n /14 /1977
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESSSAmi Conductor
5. PLACE OF BIRTH~b~~~~~~:irI'1Y~~OT USA)
6. FATHER
A. NAME Wayne Joseph CI~rk
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME M(;lri~n Fr::.lncis Guccia
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGcG I a rk
(OPTIONAL - SEE REVERS'299_60_4095
D. SOCIAL SECURITY NUMBER
12 RESIDENCE NY put chess
(ST~TE) (COUNTY)
C. CHECK ONE ....0 CITY 0 TOWN 0 VILLAGE
AND 0 hk .
SPECIF'I_ oug eepsle
D. STREETADDRESP North Randolph Ave.
10
YES 9 NO
~7
YEAR
13. A. AG630
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATlo~ngineer
B. TYPE OF INDUSTRY OR BUSINESSSeml Conductor
15. PLACE OF BIRT~anton, Ohio
(CITY, STATE / COUNTRY IF NOT USA)
lB. FATHER
A. NAM~obin Alan Kelp
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAMEJoan Frances Sonnhalter
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
D(fTH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. OATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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
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
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marnage state. ~ C L ..: -1-:: A ~
21.SIGNATUREOFGROOM~ 22.SIGNATUREOFBRIDE~ - ~-
. USE CURRENT NAME 9/10/2 08
23. ~~J~~~~DO~~O~~Ot~ ~~A6m~E~ BEFOR DATE 0
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law !l11to 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
r-I'-.
{ SEAL }
'-v-I
NAME (PRINn
TIME
MONTH
YEAR
MONTH
YEAR
09 2008
AM
03:31 PM
09
11
2008
11
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AN
PLACE INDICATED.
IVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
IF~~~~~-L.
NAME (PRINn
SIGNATURE~
DOH-98 (03/2006)