123
+
o
en
L{)
Nw
~S
fI)
>-
Z
w
- en
z
-W
o
-:i
t
tz
;::g W
~~ ...
p; c(
3m 0
'6 i:L
!:C/} _
3... t-
10 a:
~g! w
J;3 0
~
CITYfTOWN Wappinger
~~~:~~T 1368
~G~~~~R 123
Ut:t-'AH rMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
H~rnld O'Connor Kennedv
MIDDLE CURRENT S[il'jNAME
-. - ,. ..... ........... """'1'-'1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lisa Bernice Ferguson
MIDDLE CURRENT SURNAME
~
1 . A FULL NAME
11. A FULL NAME
FIRST
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)423 90 7350
D. SOCIAL SECURITY NUMBER ___ - __ - ___
2. RESIDENCEA. NY B. New York
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY New York
D STREET ADDRESS 351 W. 42 St. Apt. 1812 ZIP 10036
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3 A AGE 47 3B, DATE OF BIRTH 07 / 13 /19R1
MONTH DAY YEAR
3B. DATE OF BIRTH
07
MONTH
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kennedy
(OPTIONAL - SEE REVERSE)073 56 5343
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappinaers Falls
D. STREET ADDREss2692 West Main Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES 0 NO
~O A961
DAY YEAR
13. A. AGE47
...
>
<(
4. EMPLOYMENT
A. USUAL OCCUPATION Counselor
B. TYPE OF INOUSTRY OR BUSINESS Mental Health
5. PLACE OF BIRTH Manhattan, Ny
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Walter S Kennedy
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Virtoria E. McElrath
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATION Paralegal
B. TYPE OF INDUSTRY OR BUSINESS Leqal
15. PLACE OF BIRTH Yonkers, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Benjamin Roy Ferguson
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Arlene Frances Y ounq
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 04 / 14 / 2008
MONTH DAY YEAR MONTH DAY, . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? i'!1 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
o 0 1ST 04/14/2008 Westchester County. Ny 0 ~
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
edge and belief that the information I provided is true and that I declar at no legal impediment exists
p'
DEATH
o
DEATH
o
21. SIGNATURE OF GROOM.
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEF
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
{ } NAME (PRINT) Jo C. Ma te son
TIME MONTH YEAR
SEAL SIGNATURE'- DATE 09/03/2008
'-- -.J MAll..I~G"AP,.D!lEi$eS 1 0 20 AM
-v- LU IVIIOOII sh Rd, Wappingers Falls, NY 12590 : 09
STREET CITYITOWN STATE ZIP PM
~~~R~~RT:~ 6~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATI" AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
I
DATE 09/03/2008
by New York Domestic
MONTH
YEAR
04
2008
11
02 2008
28. PLACE WHERE MARRIAGE OCCURRED
1 XD<<:;IVIL
A. STATE NEW YORK B. COUNTY WEST
29. OFFICIAN
NAME (PRI
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
DeCITY OF 0 TOWN OF 0 VILLAGE OF
TITLE
JUDGE
10-10-2008
MOUNT VERNON
SPECIFY
NAME (PRINT)
SIGNATURE'-
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE'-