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COUNTY fJutchess
CITYfTOWN Wappinger
~~~:~CRT 1368
~~~':~~R 1 00
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Da\(j,aL~ames HoJ!~~VSURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kric:::tlrDbL~II;1rie HII~~~T SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B BIRTH NAME, IF DiFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. S~~~~t'~M~E~rt~~C~~stlolliday
D. SOCIAL SECURITY NUMBER 080-66-0073
12. RESIDENCE A. NY B. Dllt~hess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY Iii'! TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREET ADDRESS 19 Wend over Drive ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 28 3B. DATE OF BIRTH 11 /13 /1'979
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER nq 1-R4-4Rq6
2. RESIDENCE A. N';(TATE) B. 9c~!:Mi~ess
C CHECK ONE 0 CITY 121 TOWN 0 VILLAGE
AND P hk .
SPECIFY 0110 pprC:::le
D. STREET ADDRESS 19 Wendover Drive ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 29 3B. DATE OF BIRTH MOJJ. / 011 / yl;;l78
4. EMPLOYMENT
A USUAL OCCUPATION H\lAC TE'!dmici;m
B. TYPE OF INDUSTRY OR BUSINESS I or.::!1 38
5 PLACE OF BIRTH fc?.x,~t~~ /~O~~RY~~OT USA)
6. FATHER
A. NAME D<;l\lid William Hnllid;lY
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME I inrl::! H Sr:hmitt
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL 'ANNULMENT
n 0
14. EMPLOYMENT
A. USUAL OCCUPATION Tp.::!r.hpr
B. TYPE OF INDUSTRY OR BUSINESS Beacon City CSD
15. PLACE OF BIRTH Mount Kisco, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME .I::!mps .Iohn HllOhps
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Kathleen Duffy
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
o
DEATH
n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
13) 0 ANNULMENT
/ /
(2) 0 DEATH
13) 0 DIVORCE
13) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
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
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
o 1ST
o 2ND
o 3RD
o 4TH
nd belief that the information I provided is true and
o 0
o 0
o 0
o 0
aiment exists
22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED ANO SWORN TO/AFFIRMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork State of the bri 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
TE 08/04/2008
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME MONTH OAY YEAR MONTH YEAR
DATE
AM 08 05 2008 10 03 2008
03:35PM
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL STATE NEW YORK B. COUNTY {)\A.1l;Ih!S.5
A.
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF l8"TOWN OF 0 VILLAGE OF
tC AS- L..s H "" I L. j,..,
SPECIFY r-,..,. I /-L r-
/!JfJ.e I.. ovJ
TITLE {.~l.lC 'R ~~5r
DATE~(c;..{O~
'f2g fI-c ewall J~^,ctt>Jl N\
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) TI F FA ,J , i3
SIGNATURE~
DOH-98 (0312006)
SIGNATURE~