107
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
~5~~J~R 107 OJ.JI\. CERTIFICATE OF
~ CORRECTED JjY AFFIDAVIT "!:J/O<O MARRIAGE
FROM THE GROQrt
Robert Fre~ck DeWit
FIRST MIDDLE CURRENT SURNAME
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COUNTv Dutchess
CITYITOWN Wappinger
DISTRICT 1368
NUMBER
FULL NAME
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 097-62-6817
0, SOCIAL SECURITY NUMBER
2 RESIDENCE A, New York B, Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
;~CIFY Wap..Qinger
D. STREET ADDRESS 7 Plaza Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
09 / 22 / 1975
MONTH DAY YEAR
3. A. AGE 30
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS DeWit Insurance Agency
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
6, FATHER
A. NAME Robert Frederick DeWit
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Alicia Mary Reynolds
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARRIAGE
9. ~R~~~~~RM6'r~I('&~8us MARRIAGES WHICH ENDED BY
DIV08CE CIVIL ANN~LMENT
DEYf
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEA'JH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF OECREE PLACE ISSUED AGAINST WHOM
(MONTH, OAY. YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
YEAR
I
"I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
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L D SUPPLEMENTAL FILE
FROM THE BRIDE
Kristen Marie Dell
MIDDLE CURRENT SURNAME
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11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Dell - Dewit
(OPTIONAL. SEE REVERSE) 074-70-8456
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B, Dutchess
(STATE)..J (COUNTY)
C. CHECK ONE D CITY L..:J TOWN D VILLAGE
~~~CIFY WapQinger
D. STREET ADDRESS 7 Plaza Road ZIP 12b~O
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES r5 NO
04 /30 )f977
DAY YEAR
13, A. AGE 29
3B, DATE OF BIRTH
MONTH
14, EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDU~RY OR B~SINESS Wapplngers School DISt.
15. PLACE OF BIRTH' ough"eepsie, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William Joseph Dell
'B. COUNTRY OF BIRTH USA
17. MOTHER . .
A, MAIDEN NAME Melame Ann Galbraith
B, COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVrOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
DEtfH
(3) D ANNULMENT (2) D DEATH
/ /
~ YEAR
B, HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to e
as to my right to enter Into the marnage stat .
21. SIGNATURE OF GROOM~
D D 1ST
D D 2ND
D D 3RD
D D 4TH
knowledge and belief that the information I provided is
D
D
D
D
ent exists
YEAR
09
24 2006
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFOR
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
W Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
tn D If checked. this license is to be used onl for the purpose of a second or subsequent ceremony.
Z r-I'-.. 24, TOWN OR CITJ811 25, A, SOLEMNIZATION PERIOD BEGINS
W { } NAME (PRIND
~ SEAL SIGNATURE~ DATE 07/26/200 TIME MONTH
~ MAIL~ t9WtMfe ppinger Falls, NY 12590 05:2~~ 07 27 2006
STREET CITYrrOWN ZIP
~~~R~:RT~~J 'O~O~~N~ZEE~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME AY YEA
DATE AND AT THE TIME AND :7 ~
PLACE INDICATED. \J.' ()(J PM
STATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 D OTHER, SPECIFY
29, OFFICIANT
NAME (PRINT)
SIGNATURE ~
MAILlN~DDRE
1-/,0
STREET
30. WITNESS TO
NAME (PRIND
SIGNATURE~
DOH-98 (0312006)
28. PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
A. STATE NEW YORK B, COUNTY~
C. LOCATION OF CEREMONY I '3
(CHECK ONE AND SPECIFY)
D CITY OF !:i(' TOWN OF D VILLAGE OF
SPECIFY C'~+ 1-\"1.kk,\\
17..., <i<S
NAME (PRINT)
SIGNATURE~
STATE OF Nc.~ '1c:XV-
COUNTY OF ~
} SS:
Affidavit for
Correction of Marriage Record
FOR OFFICIAL NYS USE ONLY
Slate File # OOls'~ - Oc..M
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Date Com leted: 1I-f):J..-()fL:, ~
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
VVe, Robert Charles DeWit
(Groom)
being severally sworn, depose and say that
and
Kristen Marie Dell
(Bride/Maiden Name)
1. VVe reside at 7 Pl Sl7.Sl Road. Wappin~ers Falls.
(Street Address)
2. Marriage License issued by CityfTown: Town of Wappinger
New York
(State)
12590
(Zip Code)
3. Date of Marriage: July 28. 2006
4. Error(s) appearing on record (list exactly):
a. 1. A. Robert Frederick DeWit
b.
c.
5. Correct information as it should appear (list exactly):
a. 1. A. Robert Charles DeWit
b.
c.
6. Documentation Submitted:
a. COpy of Driver's License
b. Copy of Certified Transcript of Birth
c.
~
This affidavit with supporting documentation is being made for the purp e of aving the record of marriage show the
true facts and this affidavit will become a permanent record. The mar age r
~
Signature of VVife
Subscribed and sworn to
(affirmed) before me this ~~ day of .(\~\l~
Notary Public ~ ~. I' llN ~YSt~.\cto
" ".;';1 "it_V ·
. No. ~637828
NOTE: Certificate of Authenticity required for nota't"1ia ~~~jrk State
C'J;..;.~tiSion ~August3.t.:'3..\D
DOH-1827 (05/2004)
, 2DD~
(over)
SFi:\= o~s I.( ~ q -D(01\1
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
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SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
August 28, 2006
To Whom It May Concern:
Re: Correction of Marriage Record - Form #DOH-1827
District # 1368, Register # 107
Please be advised that the mistake in typing the groom's middle name was made in error
by me as I read the incorrect middle name on his birth certificate. At the time, the groom
also did not pick up on the error when reviewing it before signing the document.
It should read: Robert Charles DeWit and NOT Robert Frederick DeWit (his father).
Please see attached form # DOH-1827 Correction Form. Also enclosed are copies of his
certified birth certificate and driver's license.
Sincerely,
J~ ;f~~'
Sandra Kosakowski
Deputy Town Clerk
Town of Wappinger District # 1368
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NEW YORK STATE
DEPARnlENT OF HEALTH
BUREAU OF VITAL RECORDS
CERTIFICATE OF BIRTH
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N.V.STATE DEPT.
OF HeALTH VR FILE
TYPE ALL ENTRIES OR PRINT IN PERMANENT BLACK INK.
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12590
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_~IISTATE OF NEW YORK
.,., DEPARTMENT OF HEALTH
Corning Tower
The Governor Nelson A. Rockefeller Empire State Plaza
Albany, New York 12237
Antonia C. Novello, M.D., M.P.H., Dr.P.H.
Commissioner
Dennis P. Whalen
Executive Deputy Commissioner
November 2, 2006
Groom:
Bride:
Robert Charles DeWit
Kristen Marie Dell
Dear Town/City Clerk:
Enclosed is a copy ofthe marriage referred to by the above file in your office.
Correction to the original has been made based on:
IZI Affidavit
o Court Order
o Officiant's Statement
o Signature on original marriage affidavit
o Statement verified by City/Town Clerk
o Other: Supplemental
Please file this amended record along with the supporting documentation.
If you have any questions, please call us at (518) 486-3301.
Arle eres
New York State Dept. of Health
Vital Records Section
Marriage Registration Unit
P.O. Box 2602
Albany, NY 12220-2602
Enclosure