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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tr~ Jon K:::lf!!MileNTsuRNAME
COUNTY Dutchess
CITYfTOWN \^'appinglir
DISTRICT . .
~~~I~~~R1 368
NUMBER 129
1. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER G8Q 78 54Q5
2. RESIDENCE A. NV B. n, ,~"hess
ISTATE) .,.oolMi'Y'j
C. CHECK ONE 0 CITY JLI TOWN 0 VilLAGE
AND
SPECIFY Wappinger
D STREET ADDRESS 510 Maloney Road I 6 ZIP 1 ?Rn3
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
MJM: / ';,.7 / ~3
3. A. AGE 25
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Automotive Sales
B. TYPE OF INDUSTRY OR BUSINESS Automoti\le
5. PLACE OF BIRTH ~tY
(. C NOT USA)
6. FATHER
A. NAME Frederick Kaftan
B. COUNTRY OF BIRTH U S P-
7. MOTHER
A. MAIDEN NAME Kathleen Mary Durkin
B. COUNTRY OF BIRTH U S .A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ann~.lIMfrie La\Nr~bk~~T SURNAME
-.J
11. A. FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. s~~~~~tf'R~~~t~~c~~~afta n
D. SOCIAL SECURITY NUMBER 11 7 -6A.-1 ~ 7 A.
12. RESIDENCE A.NY B. Dlltr-h""5i5
(STATE) TC~/jlyj
C. CHECK ONE 0 CITY ol2l TOWN 0 VilLAGE
AND \^' .
SPECIFY appl'10er
D. STREETADDRESsfi1n M;:)lnm~y Rn;:)rll 6 zIP12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES otJ NO
13. A. AGE 28 3B. DATE OF BIRTH Q~TH /of bAY .1 ~~p
14. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS r.lltlAry
15. PLACE OF BIRTH ~11~~;l~E'/ ~~RY IF NOT USA)
16. FATHER
A. NAME william Robert Lawrence
. B. COUNTRY OF BIRTHl J S A
17. MOTHER
A. MAIDEN NAME .I~np.t I ynn Rp.nA
B. COUNTRY OF BIRTHl , S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o
o
DEATH
n
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
o 1ST
o 2ND
o 3RD
o 4TH
lief that the information I provided is true
o 0
o 0
o 0
o 0
o legal impediment exists
22. SIGNATURE OF BRIDE ~
9
DATE 09/08/2008
by New York Domestic
This license aulhorizes 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
~U1>.er>1U 0
DATE 2. 0 / 0 i
~ Mf IOS/2-
STATE
W
C/J
Z
W
(,)
:J
~
{ SEAL }
'-.t-'
NAME (PRINT)
29. OFFICIANT
NAME (PRINT)
SIGNATURE .-
MAJI.lNG ADDR~. .
/ ::> 1- {2:::!.LLIE r
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) '/~/-eso.... Z. !30JJc.hpf'/'
(~oI.(~~
SIGNATURE'-
DOH-9B (03/2006)
TIME
MONTH
YEAR
MONTH
YEAR
10:03AM 09
PM
09
2008
11
07 2008
10 CIVil
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ;. TOWN OF 0 VilLAGE OF
SPECIFY \~??lr-J{f ~! h
NAME (PRINT)
SIGNATURE'-