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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Seth Adam Tell
MIDDLE CURRENT I?URNAME
COUNTY Dutchess
CITYfTOWN WappinQer
~~J:~; 1368 '
~~~~;~R 128
1 , A, FUll NAME
FIRST
a.
N
B: BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 123-56-5320
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Ulster
(STATE) (COUNTY)
C. CHECK ONE 0 CITY lY" TOWN 0 VILLAGE
~~CIFY Wallkill
D. STREET ADDRESS 323 Garrison Woods Lane ZIP 12589
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r::f NO
3. A. AGE 30 3B. DATE OF BiRTH 11 / 21 / 197
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS William Tell Hardware
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME David Alan Tell
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Arlene Virginia Lynch
B. COUNTRY OF I;lIRTH USA
B. NUMBER OF THIS MARF,lIAGE 1
9. ~~~~~fR~FR~ItM8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
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) (ClTYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, deP.0S8 and sa
as to my right to enter into the
21. SIGNATURE OF GROOM ~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Brooke Kutner
MIDDLE CURRENT SURNAME
..J
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAlDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Tell
(OPTIONAL. SEE REVERSE) 123-72-9010
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Ulster
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r::Y' TOWN 0 VILLAGE
~~~CIFY Wallkill
D. STREET ADDRESS 323 Garrison Woods Lane ZIP 12589
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
13.A. AGE 29 3B.DATEOFBIRTH 03 /14 /1977
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION ManaQer
B. TYPE OF INDUSTRY OR BUSINESS Country Gallery
15. PLACE OF BIRTH Cold Spring, New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Kenneth Bruce Kutner
'B. COUNTRY OF BIRTH USA
17, MOTHER
A. MAIDEN NAME Janice Ann Wood
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANN~LMENT
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
DEAQH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
o 0 1~ 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
edge and belief that the information I provided Is true fnd that I declare t~o legal impediment exists
22. SIG RE OF BRIDE~ ~'L.tk E'J~~/'l._e..'-
USE CURRENT NAME 08/21/2006
DATE
by New York Domestic
DATE 08/21/200
Rd, Wappinger Falls, NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
M . 0 0 RELIGIOUS
9 0 OTHER, SPECIFY
...;....
NAME (PRINT)
SIGNATURE~
ooH-9B (0312006)
TIME
MONTH
YEAR MONTH
YEAR
01 :2~~
08 21 2006 10 19 2006
1J1 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. Cou~JiC.HEE~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )II' TOWN OF 0 VILLAGE OF
SPECIFY l1J I'tf>pj N~ 0
"
