016
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~~c: 1368
~G~~~~R 16
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
I
STATE FilE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
+
/ FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME R~an Charles O'Neil 11. A. FULL NAME Denyse Easton Hurlbert
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
.. B. BIRTH NAME, IF DIFFERENT
N B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C SURNAME AFTER MARRIAGE 0' N e i I
(OPTIONAL - SEE REVERSE)071 72 5478 (OPTIONAL - SEE REVERSE)092 58-3860
D. SOCIAL SECURITY NUMBER -- D. SOCIAL SECURITY NUMBER -
2. RESIDENCE A. NY B. Ora~e 12. RESIDENCE A. NY B Dutchess
(STATE) (COUN (STATE) CITY ~ (COUNTY)
C CHECK ONE 0 CITY <lJ TOWN 0 VilLAGE C. CHECK ONE 0 TOWN 0 VilLAGE
AND Newburgh ~~~CIFY Wappinqer
SPECIFY
o STREET ADDRESS 1 Wood Terrace ZIP 12550 D. STREET ADDREss20 DeGarmo Hills Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES '6 NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES tJ NO
3. A. AGE 26 3B. DATE OF BIRTH 10 /o? /1981 13. A. AGE 31 38. DATE OF BIRTH 04 ' ~9 /1'976
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT 14. EMPLOYMENT
w A. USUAL OCCUPATION FirF!m;::! n A. USUAL OCCUPATION Emergency Dispatcher
t-
'"
In B. TYPE OF INDUSTRY OR BUSINESS EMS B. TYPE OF INDUSTRY OR BUSINESS EMS
5. PLACE OF BIRTH Middletown, New York 15. PLACE OF BIRTH Yonkers. New York
(CITY, STATE / COUNTRY IF NOT USA) (CITY, STATE I COUNTRY IF NOT USA)
6. FATHER 16. FATHER
I- A. NAME D~\Iirl AlfrF!rl O'NF!il A. NAME John Nielsen Hurlbert
:> B. COUNTRY OF BIRTH USA B. COUNTRY OF BIRTHU S A
c(
C 7. MOTHER 17. MOTHER
i:i: A. MAIDEN NAME .lo;::!nne M;::!ria Knapp A. MAIDEN NAME Kay Young
u.
c( 8. COUNTRY OF BIRTH lJ S A B. COUNTRY OF BIRTHU S A
8. NUMBER OF THIS MARRIAGE 1 18. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGE~
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVI US MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
0 n 0 1 0 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? 12/ 06 / 2006'
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES DNO D. ARE ANY FORMER SPOUSE(S) ALIVE? C!"YES ONO
,.
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
1ST 0 0 1ST 12/06/2006 City Of Poughkeepsie 0 1'5
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my ~e and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marr~state. - ~ a ~
21. SIGNATURE OF GROOM~ ~J-V\. ~ ' 22. SIGNATURE OF BRIDE~~. So.<:l..... ~ ~ ^ ~,
"" USE~ ~ \ USE CURRENTNAM
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME ;-.P' A P 03/11/2008
SIGNATURE OF TOWN OR CITY CLERK ~ . t 1 DATE
/ This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
W Relations Law 911 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
UJ o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS 25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON,
W } ",""em"" In~t~ MONTH I DAY I YEAR MONTH I DAY I YEAR
0 TIME
::i {SEAL SIGNATURE ~ . C. DATE 03/11/2008
MAILING ADDRESS 11 :44AM
'" '-v-I fE9 Midd1ebllsh Rd '^'~rg.i~r~ F;::!II~ NY 1?!1~0 PM 03 12 2008 05 10 2008
STR ' ITV N 'STATE ZIP
/ I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY 28. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME I MO. DAY YEAR o ~ RELIGIOUS 10 CIVIL NEW YORK Dutchens
DATE AND AT THE TIME AND 4:00~1 3-21-2008 A. STATE 8. COUNTY
PLACE INDICATED. 9 0 OTHER, SPECIFY
W C. LOCATION OF CEREMONY
.... 29. OFFICIANT . 1 d (CHECK ONE AND SPECIFY)
c( NAME (PRINT) Danle B. War TITLE Pastor B CITY OF 0 TOWN OF
0 SIGNATURE~ ~J!ar-~ o VILLAGE OF
i:i: DATE 3-28-2008
i= MAILING ADDRESS , SPECIFY Poughkeepsie
a: St. John's Lutheran Church 55 Wilbur Boulevard. Pok. NY 12f 03
W STREET CITYfTOWN STATE ZIP
0 30. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
NAME (PRINT) Jason Hermance NAME.(PRINT) TraC'.v T.nml-"'rdo
'" SIGNATURE~ I/d... :../ ./ SIGNATURE~ ~ ~ t1,~~.
DOH-98 (D3I2DD6~ (
L 0 SUPPLEMENTAL FILE
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