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COUNTY Dutchess
CITYfTOWN Wappinqer
~~~:~c; 1368
~G~~;~R 41
~ I A. I r:: ur I~r:: YV ,unl\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin Scott Johnson
MIDDLE CURRENT SURNAME
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Vanessa Chrystelle Molenaer
FIRST MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Johnson
(OPTIONAL. SEE REVERSEJ057_74_0971
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY t'J TOWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREET ADDREss23 Dennis Road
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEJ
D. SOCIALSECUAITYNUMBER 063-72-5404
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE ..tJ CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
D STREET ADDRESS 26 Mackin Avenue ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? l!'l YES 0 NO
1? / 1 A / 1983
MONTH DAY YEAR
ZIP 12590
o YES~ NO
/1'982
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 25 3B. DATE OF BIRTH 10 /02
MONTH DAY
3. A. AGE ?4
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Correction Officer
B. TYPE OF INDUSTRY OR BUSINESS Corrections
5. PLACE OF BIRTH Pouahkeepsie, NY
(CITY, S"I'ATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME .1::lmF!~ Christi::ln Johnson .Jr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Bonnie Mellis Nameth
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
14. EMPLOYMENT
A. USUAL OCCUPATION Assistant Manaaer
B. TYPE OF INDUSTRY OR BUSINESS Retail
15. PLACE OF BIRTH Bronxville , New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Jean - Jacques Molenaer
'B. COUNTRY OF BIRTHFrance
17. MOTHER
A. MAIDEN NAME Emilv Ann Croce
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER'OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
C. DATE LAST MARRIAGE ENDED?
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to th
as to my right to enter into the marriage st ;/
21. SIGNATURE OF GROOM~
o
o
1ST
2ND
3RD
o
o
o
w
en
z
w
(,)
::i
23. SUBSCRIBED AND SWORN TOIA RMED B
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
DATE 05/01/2008
by New York Domestic
~
{ SEAL }
"-v-I
NAME (PRINT)
TIME MONTH YEAR MONTH YEAR
11 :32AM 05 02 2008 06 30 2008
WN STATE PM
27. TYPE OF CEREMONY 28. PLACE WHERE MARRIAGE OCCURRED
o ~ RELIGIOUS 10 CIVIL NEW YORK B.COUNTY~~~
'Qq ~ A. STATE
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED A80VE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ITY OF 0 TOWN OF 0 VILLAGE OF
TITLE
M ~Ni STeR.
S-oot-o~
r2.~
ZIP
31. WITNESS TO CEREMONY
) .-'
SPECIFY
~60~
NAME (PRINT)
SIGNATURE.