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COUNTY Dutchess
CITYffOWN WappinQer
~~~:~c; 1368 '
~~~I;~~R 11
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MRtthMYo'tte DonRld ~~~r~R~NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kimbjf!o'~ Lynn R~~~E~T~URNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 064 54 3712
D. SOCIAL SECURITY NUMBER ___ - __ - _
2. RESIDENCE A. Np.w York B. [)lItc:hp.!';!';
(STATE) (COUNTY)
C. CHECK ONE 0 CITY /ii!f TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 45 Middlebush Road. Apt. 41P 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES I!l' NO
3. A. AGE ~!=i 3B. DATE OF BIRTH O~ / ?? / 197j
MONTH MY Y~R
a BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAMEAFTERMARRIAGE Kennedy
(OPTIONAL. SEE REVERSE) 097 68 0257
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY [l( TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 45 Middlebush Road, Apt. 2zIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 36 3B. DATE OF BIRTH 04 /07 /1970
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION ~p.nAml ContrRctor
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Medina, New York
(CITY,. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME nonRlrl FrRnc:i!'; KAnnArly
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Virginia Louise Lilly
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 0
14. EMPLOYMENT
A. USUAL OCCUPATION Residential Painter
B. TYPE OF INDUSTRY OR BUSINESS Construction
15. PLACE OF BIRTH North Tarrvtown. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Kingsley Westover
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Helen Katherine Spampinato
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
'DIVORCE" . . CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. '.~ YEAR
B. HOW DID LAST MARRIAGE END?
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, Y~R) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
e best of my knowledge a
1ST
2ND
3RD
o 0
o 0
o 0
o 0
ediment exists
OF BRIDE ~
~
{ SEAL }
"-v-I
ride and groom named above by any person authorized
THIS LICENSE VALID IN NEW YORK STATE ONLY.
for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by New York Domestic
NAME (PRINT)
YEAR
TIME
MONTH
YEAR
MONTH
SIGNATURE ~ DATE 02/21/200
MAILING ADDRESS 1 0: 17AM
STRE~P Middlebush Rd. WaPcP~~~~r Falls. S~A~ 12590ZlP PM
I CERTIFY THAT I SOLEMNIZED 26 SOLEMNIZATION OCCURRED 27~TYPE CEREMONY
THE MARRIAGE OF THE PER. .
SONS NAMED ABOVE ON THE TIME MO. DAY Y~R 0 LIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
02
22
2007
04
22 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY'bVTOff5S
C.
SIGNATURE~