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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin Michael Bennett
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~:~c; 1368
~~~liJ~R 47
1 . A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 095-70-4041
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
AND P hk '
SPECIFY oug eepsle
D. STREET ADDRESS 12 Arbor Hill Drive ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
OR /01 /19R5
MONTH DAY YEAR
3, A. AGE 2?
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Banking
5. PLACE OF BIRTH Pouahkeepsie, Nv
(CITY, ~ATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME navirl lllrick Rt=mnett .Ir
6. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kathryn Marie Meenagh
6. COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGE8
A. NUMJlSg?JlRl:VI . us MAB.RII\G~it;t'~I~~uI~~~~ BY
n 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
I'
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Caren Jean Andresen
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Bennett
(OPTIONAL - SEE REVERSE) 8 6
D. SOCIAL SECURITY NUMBER 1 33-70- 94
12. RESIDENCE ANY B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinqer
D STREET ADDRES~4 Four Wheel Drive
ZIP 12590
o YES '6 NO
A986
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13 A. AGE 21 36. DATE OF BIRTH 07 Aj5
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Student
6. TYPE OF INDUSTRY OR BUSINESS Publishinq
15. PLACE OF BIRTH Danbury, CT
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Thomas Brian Andresen
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A, MAIDEN NAME Catherine Jean Arena
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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
IX:
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o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
y knowledge and belief tOi!tlhe information I provided is true and that I declare that no legal impediment exists
1ST
2ND
3RD
4TH
I duiy swear/affirm, def)ose and say, that to t
as to my right to enter into the m.'~rna?e~
21. SIGNATURE OF GROOM ~ '
S
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork State of the bride and groom named above by any person authorized
Relations Law S11 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
~
{ SEAL }
~
NAME (PRINT)
22. SIGNATURE OF BRIDE~
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
05:21 PM 05
2008
07
06 2008
08
ITY WN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STATE
27, TYPE OF CEREMONY
01'l RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY 'i)iJ it HE: ~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
1=="\SI-f~)'-L
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
5 ZS" 0
~~rJ:mi;mT R € \I, J 0 H ~ !v1, -{ 0 I.) t-.J Go
SIGNATURE~ &..11 ~ ,;V\ 'f~
MAI~I~G ADDRESS / ----c:::.:r
1,00 R" ~'2.. 'FlHf ~ I \..l.
STREET CITYfTOWN
30, WITNESS TO ~REMONY
NAME (PRINT) /
TITLE
DATE
IVy
STATE
SIGNATURE~
DOH-98 (03/2006)
PAS,..-o R..
SPECIFY
SIGNATURE~