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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
Dutchess
COUNTY \Nappi
CITYITO~_ nger
DISTRiCT!
NUMBER 46
REGISTER
NUMBER
FIRST
MIDDLE
CURRENT SURNAME
L 0 SUPPLEMENTAL FILE
Katheri~~~'tiaR~~-Manning
11. A. FULL NAME
FIRST ~Ui:ter CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME)'~fFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE>134-64-6.287
o SOCIAL S~TAj!k Dutchess
12. RESIDENCE A. B.
(ST A TEl". (COUNTY)
C. ~6CK .ppiJI._ 0 TOWN 0 VILLAGE
SPECIFY. 22 Vontdlan Drive 12590
D. STREET ADDRESS ZIP .,
E. IS R~~NCE WITHIN LIMITS OF CITY OR INCORPORA~ VILLAGE9s 0 1~ NO
13. A. AGE 13.B. DATE OF BIRTH __
MONTH DAY YEAR
14. EMPLOYMENT Promotional Advertising
A. USUAL OCCUPATION Self - Employed
B. TYPE OF IND!H 1'IfIYurk
15. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Robert Anthony Hutter
A. NAME USA
B. COUNTRY OF BIRTH
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B. BIRTH NAME. IF DIFFERENT
C. S~~~~~JN~~~~~t~~e~sEQ96.14-5511
o SDCIALSE~'~
2. RESIDENCE A. B. 01Seg0
(STATE) ., (COUNTY)
C. ~6CK 01kJttemai 0 TOWN 0 VilLAGE
SPECIFY P. O. Box 175 13118
D. STREET ADDRESS ZIP ~
E. IS RE~~NCE WITHIN LIMITS OF CITY OR INCORPORATE~GE? J)'7D YES ~~
3. A. AGE 3B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
4. EMPLOYMENT "
A. USUAL OCCUPATION Hoar Tnmmer
B. TYPE OF IND~~S~o.t Em~uyed
5. PLACE OF BIRTH ' T
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER M"--'" ... HII
A. NAME I.... - .,.mes
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Barbera Jean Larsen
B. COUNTRY OF BIRTH U 5, A
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVIfCE CIVIL A~ULMENT
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17. MOTHER elizabeth Mary Plank
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 2
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES .
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A'O'UlMENT
~
D1:)TH
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVOIfOf (3) 61NNULM~D DEATH
C. DATE LAST MARRIAGE ENDED? MON'" / DAY -----vEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
1'fJtj;f.8XH~N~cWf SijIf SPOUSE
o 1ST ' . 0 0
o 2ND 0 0
o .3RD 0 0
o 4TH 0 0
ief that the information I provided is true and that I declare that no legal impedim nt exists
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES P NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the best of my
as to my right to enter into the marr!f1ge state.
J.'
21. SIGNATURE OF GROOM ~ .
IGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta
Relations Law ~11 to perform marriage ceremonies within
o If checked, this license is t
~ 24 TOWN OR cJOhli~. Masterson
{ } NAME (PRINT) ~
SEAL SIGNA~~~~'~ CltL~~ ~ DATE05ID8I2OO6
"-y-I M2f)J~Rd, ppinger Falls, NY 12590
STREET CITYITQWN STATE
~~~R~~~Ri~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ijY'CIVll
DATE AND AT THE TIME AND AM
PLACE INDICATED. Ic:Jc _ 90 OTHER, SPECIFY
28. PLACE WHERE MARI'lIAGE OCCURRED
A. STATE NEW YORK B. COUNTY oJvcr'C
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY Mw"el'\.- Vi' 1/<:,.,
DATE
of the bride and groom named above by any person authorized by New
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
York Domestic
MONTH
YEAR
TIME
MONTH
YEAR
07
ZIP
AM 05
PM
09
2006
TrrLE'1bWVL Jt< S f~4..
DATE 5/2- I / /') ,
r:;~",,1( !J ~r IV ~
STAT '
~ ~,~,- jtiti ~
NAME (PRINT) ~ --
SIGNATURE ~
MAILING ADORE S f: A
( ) V mAl V\ S , rP fk."'L Ifl{ I
SIREET CITYITOWN
30. WITNESS TO CEREM
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINl
SIGNATURE ...
31. WITNESS T
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