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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~: 1368 '
~~~~J~R86
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
R,s;b~~ AI:::m N::l~RENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.Ionni M::lrip. Kirkp::ttrick
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
D.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE N::l!=:h
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 112-58-6071
12. RESIDENCE ANY BDllkhp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREET ADDRESS 1 02 Overacker Rd
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D. s~:'~~~~~E~U~~~~RSEb71_54_1558
2. RESIDENCE A. NY B. nlltr.hp.!=:!=:
(STATE) (COUNTY)
C. CHECKONE 0 CITYo,l] TOWN 0 VILLAGE
AND P hk .
SPECIFY ollg eep~le
D. STREET ADDRESS 102 Overacker Rd ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
3. A. AGE50 3B. DATE OF BIRTH 01 / 1~ /1957
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE41 3B. DATE OF BIRTH On An
MONTH DAY
ZIP 12603
OYES..o NO
Kq66
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION r.::trpenter
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH VVaterburv CT
(CITY. STATE I C6UNTAY IF NOT USA)
6. FATHER
A. NAME Frenerick Willi::tm N::t~h, .Ir
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy Yvonne NelsQn
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
14. E"!'PLOYMENT
A. USUAL OCCUPATION Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Medical Admin
15. PLACE OF BIRTH Poughkeepsie. NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Bernard Thomas Kirkpatrick Jr.
'B. COUNTRY OF BIRTJ..! S A
17. MOTHER
A. MAIDEN NAME Mary Catherine Bellinahausen
B. COUNTRY OF BIRTJ..! S A
18. NUMBER OF THIS MARRIAGE 1
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
-----DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
a:'
w
!l!
:)
Z
Q
Z
""
I;;
w
~
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE.---.-----CIVIL-ANNUI:MENT------. -
1 0
B. HOW DID LAST MARRIAGE END? (3) rJ 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? 07 / 14 / 1987' C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTH DAY' '. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
.-
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTAY, IF NOT USA) SELF SPOUSE
1ST 07/14/1987 Pierce County, Wisconsin ('1 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, oep'0S8 and sa I that to the best of knowledge and belief that the information I provided;1's and th~t I feclJre that no legal impediment exists
as to my right to enter into the age stlJte. ~ ~~. t.,...
21. SIGNATURE OF GROOM~ . 22. SIGNATURE OF BRIDE ~ ~ ~~
USE USE CURRE~E
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 08/08/2007
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New Yo bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jo n C. Masterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 08/08/2007
'- -.J M~~1OO~dr~ appinger Falls, NY 12590 AM 08 09 2007 10 07 2007
-v- 05:33 PM
STREET CITYITOWN STATE ZIP
~~~~~RTr~~ 10~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO_ DAY YEAR 0 Ii! RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY~' NY
29. OFFICIANT
NAME (PRINT)
TITLE
DATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
DOH-9B (0312006)