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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William l~othy G'lil~~bf1t Jr
FIRST M D L C Su NAME
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~c: 1368
~~~I~~~R 1 0
1. A. FULL NAME
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER n~~-7?-nn?~
2. RESIDENCE A. N'YsTATE) B. qc~~~ess
C. CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
AND P hk "
SPECIFY 0110 eprC:::IP
D STREET ADDRESS ?n~~ Sntlth Road; Apt C-5 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 2'1 3B. DATE OF BIRTH M~ / 9? / y~83
4. EMPLOYMENT
A. USUAL OCCUPATION Loss Pre\lention
B. TYPE OF INDUSTRY OR BUSINESS Rpt~il
5. PLACE OF BIRTH Be~r:nn New York
(CITY. STATE i'COUNTRY IF NOT USA)
6. FATHER
A. NAME William Timothy Guilballlt, Sr
B. COUNTRY OF BIRTH I I ~ A
7. MOTHER
A MAIDEN NAME Margaret Mary O'connor
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE' . CIVlb\NNutMENY
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
DEATH
o
(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
"I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M~ri~ n~nipllp. Rnc:::~ti
MIDDLE CURRENT SURNAME
~
1 1. A. FULL NAME
FIRST
B. BIRTH NAME (MAIOEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~ I I i I h~ I lit
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 086-76-3758
12. RESIDENCE A. NY B. nlltr.hpc:::c:::
(STATE) (COUNTY)
C. CHECK ONE 0 CITY Ii2I' TOWN 0 VILLAGE
AND P hk .
SPECIFY ntlg eepsle
D. STREET ADDRESS 2633 South Road' Apt C-5
13. A. AGE 22
ZIP 12601
OYES~NO
-1986
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
'/11
g~TH DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION T p~r.hpr
B. TYPE OF INDUSTRY OR BUSINESS Private School
15. PLACE OF BIRTH Pntlnhkeensie, NY
(CITY, ffi"ATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME StE'\Ie Ros~ti
B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME ~hpryl-I pp Ann Islir
B. COUNTRY OF BIRTH I J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
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
o
o
o
0:'
W
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the mar
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
nowledge and belief that the information I provided is true and
~
{ SEAL }
~
NAME (PRINT)
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
10;00 6.3
PM
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
""
DATE
22. SIGNATURE OF BRIDE ~
DAnE
02/25/2008
by New 'York Domestic
TIME
YEAR
MONTH
YEAR
MONTH
02/25/2008
AM
03:42PM
26
2008
04
25 2008
IP
02
A
27. TYPE OF CEREMONY
o B:..RELIGIOUS
9 0 OTHER, SPECIFY
oV"J..tJ,)'n ~ yiI\<Vl i'1 'i-e iI
S-;I>-V&
(2->76
STATE ZIP
31. WITNESS~ TO REMO NY, ~n) t:l
NAME (PRINT) 0 b\~ ~ ~ ')
SIGNATURE~ ~
DATE
IVY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY DVt.tJ,~-s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY &},,- f:"{5, h l<1 \ ,