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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~ 1368 '
~~~~J~R 136
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
James Hession Whalen
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPAf;E FOR STA TE USE ONL YI
I
L 0 SUPPLEMENTAL FILE
~
1 ' A. FULL NAME
FROM THE BRIDE
Kathleen Marie Carielli
FIRST MIDDLE CURRENT SURNAME
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT Ruth
C. SURNAME AFTER MARRIAGE W ha len
(OPTIONAL - SEE REVERSE) 060-48-5357
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE)..J (COUNTY)
C. CHECK ONE 0 CITY L.::J TOWN 0 VILLAGE
~~~CIFY LaGran~e
D. STREET ADDRESS 33 Lakevlew Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 6 NO
08 /28 )1'955
DAY YEAR
11. A, FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 054-44-0074
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY LaGrange
D. STREET ADDRESS 33 Lakeview Road
ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3, A. AGE 54 3B. DATE OF BIRTH 04 / 19 / 1952
MONTH DAY YEAR
13, A, AGE 51
3B. DATE OF BIRTH
MONTH
4, EMPLOYMENT
A. USUAL OCCUPATION Moving Consultant
B, TYPE OF INDUSTRY OR BUSINESS Barr Moving Company
5, PLACE OF BIRTH Wingdale, New York
(CITY, STATE I COUNTRY IF NOT USA)
14, EMPLOYMENT
A, USUAL OCCUPATION Bookkeeper
B, TYPE OF INDUSTRY OR B~SINESS St. Joachim - St. John's
15. PLACE OF BIRTH Mount lemon, New York
(CITY, STATE I COUNTRY IF NOT USA)
6, FATHER
I- A NAME Thomas J. Whalen
~ B, COUNTRY OF BIRTH USA
c 7, MOTHER
u: A, MAIDEN NAME Anne Molloy
~ B- COUNTRY OF BIRTH Ireland
8, NUMBER OF THIS MARRIAGE 2
16, FATHER
A, NAME Carl Frederick Ruth
'B- COUNTRY OF BIRTH USA
17, MOTHER .
A. MAIDEN NAME Rose Mane Goessmann
B. COUNTRY OF BIRTH USA
J
18. NUMBER OF THIS MARRIAGE
9, PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1VO~CE CIVIL ANN~LMENT DEAlt DIV~RCE CIVIL AN~LMENT D~TH
~ ~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 A~NfLMENT 2~5!fEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORtj5 (3) ~ULMENT 2dB~ DEATH
c. DATE LAST MARRIAGE ENDED? 02/ / C, DATE LAST MARRIAGE ENDED? / /
MONTH ~ DAY YEAR MONTH~ DAY' . - YEAR
D, ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULlLED, 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
(MONTJ"i,j 1}'Y.2~R..l.. (CITY/GOUNTY, STATElCO~RY. IF ~gr UljA) SELF SPOU", (~.Rl\k X,Ei4e.l P (CITY/CflIINTY, STATElCOU~Y, IF f\D,T U~) S~ SPOUSE
1ST 021"111; UUL Dutcness L;O., New YOrK 0 0 1ST UO/LJ/LUUJ ougnKeepsle, I~ew YOrK 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, depose and s y knowledge and belief that the information I provided is true and t impedimElllt exists
as to my right to enter into the m ~..,J
21. SIGNATURE OF GROOM~
USE CURRENT
USE CU
23. SUBSCRIBED AND SWORN TOIAF MED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK,-
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STArE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
r-I'-.. 24. TOWN OR CITJb1i~K C. Masterson 25. A. SOUEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
SEAL SIGNATURE'- DATE 08/28/200 TIME MONTH YEAR MONTH DAY YEAR
MA1L2e 1'QRffiJfe ppinger Falls, NY 12590 12 O...AM 08 29 2006 10 27 2006
'-.t-' : OpM
STREET CITYfTOWN STATE ZIP
~~~R~~RT~~~ IO~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 g-'CIVIL
DATE AND AT THE TIME AND fI & AM Q I "' 0 "'
PLACE INDICATED. ( : r r- , 0 0 9 0 OTHER, SPECIFY
~ 'Of={oR-D
DATE
25, B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou~'1C"es1'~,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY Cuvt"f(.."O.......01'"
TITL~~~1"ut.
DATE 911 (I cP'
,
I OS-I ~
~~LL
/vy
STATE
NAME (PRINT)
SIGNATURE'-
fA) hOi IeV',
~
SIGNATURE'-