120
+
o w
O'l !;;:
L!) to
N
T"""
>-
Z
f-
Z .
li@
~
~
~C/)
~
CiiQ)
zen
g~
"el.
g:el.
!!lrn
~
w
~ .
;to
iErn
~
~Q)
~~u
ii:O
~
~
w
:x:
~
(J)
(J)
w
a:
Cl
Cl
"
>-
u.
13
w
a.
(J)
+
z z
!5 g W
~ ~ l-
f- Z c(
3 ~ 0
::; 5 u;:
~ (J) 1-_
" u.
13 0 a:
it (J) W
o >-
Iii 15 0
... "'
o
z ~
:StAIt: I-ILt: NUMtlC.t1
(THIS SPACE FOR STA TE USE ONL Y)
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
AdC)mMI~Elcr ("I ry W C!t~~~ SURNAME
couNrDutchess
CITYfTowr-Wappinger
~~~:~CR1368 .
~~~I~~~~ 20
1. A. FULL NAME
FIRST
0-
N
. B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEj
D. SOCIAL SECURITY NUMBER 11 0-7R-0774
2 RESIDENCE ANYISTATE) B. D~J~S';'>j~E(SS
C. CHECK ONE 0 CIWO TOWN 0 VILLAGE
AND W .
SPECIFY ::lpplnger
o STREET ADDRES~7 Losee Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEm NO
3. A AG125 38. DATE OF BIRTH OLl. /07 A qR?
MONTH DAY YEAR
l-
S;
c(
C
wU;:
"I,L
~c(
~
;:
o
~
13
4, EMPLOYMENT
A, USUAL OCCUPATIONr,p.nlnoi~t
B. TYPE OF INDUSTRY OR BUSINEssCivil Engineering
5, PLACE OF BIRTtManhattan, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAMEn::lvici nnn::llci W::lt~nn
B, COUNTRY OF BIRTHU S A
7, MOTHER
A, MAIDEN NAME Terry Ann Gutterman
B. COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o U
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED ORANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
Not
ihfJf- 1)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Am::l~M~~ Rn~e TL1J~RENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C, SURNAME AFTER MARRIAGMI::lt~nn
(OPTIONAL - SEE REVERS~
D. SOCIAL SECURITY NUMBER -l13-7 4-0483
12, RESIDENCE.NY [)I Jtr.he~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITW'Q TOWN 0 VILLAGE
AND _\A1 .
SPECIFWvapplnger
o STREET ADDREs27 Losee Road
ZI~ 2590
o YE~D NO
1-982
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGFOf) 3B. DATE OF BIRTH 07 Q9
MONTH DAY
14, EMPLOYMENIT
A,' USUAL OCCUPATIO,speech Language Pathologist
B. TYPE OF INDUSTRY OR BUSINESJ:;arly Intervention
15. PLACE OF BIRTtBeacon. NY
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A. NAM~erard Joseph Tully, Jr.
'B, COUNTRY OF BIRTW S A
17, MOTHER
A. MAIDEN NAMMiriam Viola Filkins
B, COUNTRY OF BIRTW S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
0- n
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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
a:'
w
lC
::;
~
z
Cl
Z
"
...
w
w
a:
to
1ST
2ND
3RD
4TH
I duly swear/affirm, deRose and say, that
as to my right to enter into the mama
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the Information I provided is true and that I declare that no legal I
o 0
o 0
o D
o 0
pediment exists
23. SUBSCRIBED AND SWORN TO/A D
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yor tate 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 " 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
{ } NAME (PRINT) Jo C. Master on
.Ii) TIME YEAR
SEAL SIGNATURE~ L. DATE09/12/2007
"-t-' M~'crMfcfm~ h Rd, appingers Falls, NY 12590 6:48 ;~
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. PM 9 0 OTHER, SPECIFY
W
en
z
W
o
:J
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30, WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
CITYrrOWN
22, SIGNATURE OF BRIDE ~
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
YEAR
DAY
11
11 2007
28, PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY
STATE
ZIP
31, WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~