045
o
m
~
('II
,...
>=
z
~
~
I
I
j
1:$
d
!
5i
i
Q
.....
~
~
(/)
w
0:
Cl
Cl
'"
>-
LL
U
W
0-
(/)
z Z
0: 0 W
:::J >=
>- ~
W '"
0: N
>- Z
(/) ::; U
:::J w
::; 6 u::
>- (/)
z i=
'" LL
U 0 a:
u:
LL (/) W
0 >-
'" U
Iii Cl
~ '"
0
z ;s
1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Roi~.rt Harry OWAflS. JR
MIDDLE
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Yi
I
COUNn{)1 Jtr.hp.~~
CITYfTOWNWRppingp.r
~~~:~CRT136R
~5~lgJ~R45
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.J
0-
N
B. BIRTH NAME, IF DIFFERENT
11. A. FULL NAME.lodi I vnn Grady
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTOoolpqt
C. SURNAME AFTER MARRIAGE OWen!;
(OPTIONAL - SEE REVERSEh
D SOCIAL SECURITY NUMBER 65-60-5041
12. RESIDENCE o6N Y BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~cl~ishkill
D STREET AOORES~ 1 B Town View Drive
ZIP12590
DYES"'D NO
1Q7fi
YEAR
CURRENT SURNAME
CURRENT SURNAME
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE,\,.
o SOCIAL SECURITY NUMBER u08-62-5873
2. RESIDENCE AN '6nATE) B. ~~~
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
~~~CIFY Fishltill
D. STREET ADDREss318 Town View Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEs"tJ NO
~~H /2iAY /1W-
3 A AGE35
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGF29 13.B. DATE OF BIRTH 17 ~
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIONRetail Manager
B. TYPE OF INDUSTRY OR BUSINESsFilene's
15. PLACE OF BIRT~hinebeckl. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMe-lohn Dooley
B. COUNTRY OF BIRTIlJ S A
17. MOTHER
A. MAIDEN NAMEB~rhRrR Kommer
B. COUNTRY OF BIRTtlJ S A
18. NUMBER OF THIS MARRIAGE 2
W
t-
'"
>-
'"
4. EMPLOYMENT
A. USUAL OCCUPATION Correction Offir.p.r
B. TYPE OF INDUSTRY OR BUSINEssFi~hkill Correctional Fac
5. PLACE OF BIRT~IJtIRnrl Vermont
(CITY, STATI!JCOUNTRY IF NOT USA)
6. FATHER
I-
:>
c(
c
w-
CllL
::IlL
~c(
z
;:
o
~
>-
[)
A. NAME Robert Harry CNren!::, ~r
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Susanne Marie Kelley
B. COUNTRY OF BIRTH II " 11
8. 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
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
o 0 1 0
B. HOW DID LAST MARRIAGE END? (3)~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3)11. DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGEENDED? "7 / 19 /2004 c. DATE LAST MARRIAGE ENDED? 06 / 14 /2004
MONTH DAY YEAR MONTtJ. DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? l'J YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 07119/2004- [lutr-hf!!::~ r.:o . Nf!W York ~ 0 1ST 06/14/2004 Dutchess Co, New York ~
2ND 0 0 2ND 0
3RDD 0 3RD 0
4TH 0 0 4TH
I, being duly sworn, depose knowledge and belief that the information I provided is ~ue
as to my right to enter int e m
DEATH
o
1
0:
w
m
::E
:::J
Z
o
Z
'"
>-
w
W
0:
>-
'"
~2006
w
CJ)
Z
W
u
:J
23. SUBSCRIBED AND SWORN TO 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
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ,lohn"t'11. ~RtdfU'~on
TIME MONTH DAY YEAR
SEAL SIGNATURE ~ '
MAILING ADDRES .
'-v-I .
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND ~
PLACE INDICATED. vi PM
29. OFFICIANT /7.c.,. AL or r" / J LC n
NAME (PRINT) b-~" () ",. en'! I-LA ... rr l.... TITLE
~1~~I~1J1~6~ES~~ ~ DATE
'T J 0/"7 elL-I ~(vl:. (L I-(IN~0l:...c..-{c:
STREET CITYfTOWN
30. WITNESS TO CEREMONY / .
NAME (PRINT) ^ fAl 5
Pvrcltk:.J J
by New York Domestic
MONTH
YEAR
10:46 AM 05
PM
06
2006
07
04 2006
STATE
27. TYPE OF CEREMONY
0)1 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF :a- TOWN OF fj'>VILLAGE OF
1'- H- { /Vii 13 {.C- K.
SPECIFY .
,;:-
Efl SCOPftl..... P/l. f tZ'S J
:rlll~ c.
/V.y.
STATE
SIGNATURE ~
DOH-98 (11/98)
31.
('ueST~
NAME (PRINT)
SIGNATURE ~