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COUNTY Dutchess
CITYrrOWN Wappinger
~~.:~~ 1368 '
~~~~R72
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rr~nrl~~L~ln~~rh ~CQ~iWS~RNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kri~tin Anne .Jenkin~
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAMEAFTERMARRIAGE C. SURNAME AFTER MARRIAGE Mcr,::mn
(OPTIONAL. SEE REVERSE)054 70 7574 (OPTIONAL - SEE REVERSE)134 72-4871
D. SOCIAL SECURITY NUMBER ___ - __ - ____ D. SOCIAL SECURITY NUMBER -
2. RESIDENCE A. NY B. nlltche~~ 12, RESIDENCE ANY B,Dutchess
(STATE) (COUNlY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
AND W' ANDW'
SPECIFY appmger SPECIFY appmger
D. STREET ADDRESS 89 Chelsea Road I , ZIP 12590 D. STREET ADDRESse9 Chelsea Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED~~~fi 0 YESot! NO ,E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE?R 3B. DATE OF BIRTH ---'lZ. <Y OR / 1979 "~~;'iA" AGE28 3B. DATE OF BIRTH 03 ;12
MONTH DAY YEAR MONTH DAY
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION Teacher A. USUAL OCCUPATIONSales
B. TYPE OF INDUSTRY OR BUSINESS Minisink Vallev CSD B. TYPE OF INDUSTRY OR BUSINESS Rental Car
5. PLACE OF BIRTHRhinebeck. NY 15. PLACE OF BIRTHSouthfield. Michiqan
(CITY, STATE I COUNTRY IF NOT USA) (CITY, STATE I COUNTRY IF NOT USA)
ZlP12590
o YESot! NO
Uf79
YEAR
6. FATHER
A. NAME William Christopher Mcgann
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Donna Marie Melia
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~R~~~~8us MARRIAGES W~ICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
16. FATHER
A. NAME Tim Michael Jenkins
. B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Barbara Anne Heimbuch
B. COUNTRY OF BIRTJJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVfOUS 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
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) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.-,- YEAR
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~. 0 0 ~
I duly swear/affirm, deP.Ose and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the age state. f
21. SIGNATURE OF GROOM ~ './) 22. SIGNATURE OF BRIDE ~
o 0
o 0
o 0
o 0
d that I declare thal no legal impediment exists
, ~
USE CURRENT NAME
DATE 07/19/2007
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFOR
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New 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.
,-I'-.. 24. TOWN OR CITYJ LER~ M t 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) n 1",;. as ers
{ ~ ~ ~
SEAL SIGNATURE ~
'-.t-I ~(j1\1tl 03:39 ~~ 07 20 2007
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
by New York Domestic
MONTH
YEAR
09
17 2007
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYMC rt ( ~
C.
~re.lf)1
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~