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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
U~ Alan ~e
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY DI dcbess
CITyrrOWN Wappinger
~:rJ~~~T 1368
~5~~J~R 11
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME ~ .Ann Kt~
CURRENT SURNAME
CURRENT SURNAME
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~N~~~~t~~e~~sV.dtone
D. SOCIAL SECURITY NUMBER Q64..74-2593
12. RESIDENCEA'~A~ B. ~s
C. CHECK ONE 0 CITY 'iit TOWN 0 VILLAGE
AND tAl- .
SPECIFY v-J1P'~
D. STREET ADDREss39 CArmll Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES;JI'J NO
13. A. AGE'V-a 13.B. DATE OF BIRTH "7 ..t.. A,,(~
~ "U'iNTH ~DAY "'~AR
14. EMPLOYMENT
A. USUAL OCCUPATION SUbs6hde
B. TYPE OF INDUSTRY OR BUSINESS ~ CIty Scb DIs:t
15. PLACE OF BIRTH~T~T~Rfk
16. FATHER
A. NAMEKer1netb Joseph Kens, Sr
B. COUNTRY OF BIRTf-fJ S A
17. MOTHER
A. MAIDEN NAME Joan Ann RoncJelll
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 068-66-6878
2. RESIDENCE A ~T'todc B. q~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND tAl- .
SPECIFY VVHlPP~
D. STREET ADDRESS 39 CArroll Drive ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..tJ NO
3. A. AGE24 3B. DATE OF BIRTH MQt /qzy /1iQ2
4. EMPLOYMENT
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A. USUAL OCCUPATION Inverd'ory Control Clerk
B. TYPE OF INDUSTRY OR BUSINESS Metro ~tvfh
5. PLACEOFBIRTH~'~York
6. FATHER
A. NAME Thomas Wayne V.attone
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Rimel Ada Cusher
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? M /?A /~
MONT!!l"" M ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? !l!l'YES 0 NO
20. 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
DEATH
DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
w
en
z
w
o
::i
1 ST 0 0 1ST 05Q412OO5 Poughkeepsie, N Y 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and sa , that to the b st of my knowl dge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the ma a st . 77;1. ~ / . _ ~ /1. {J. ~
21.SIGNATUREOFGROOM~ ~~~ - --.
USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME DATE ~J1 r ~
SIGNATURE OF TOWN OR CITY CLERK ~ ~-!.- ~
This license authorizes the marriage in the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne ork 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.
{,-A-., } ~:~~::I~~)C1!~ '''''~ "k':"""'=,""'OO "G~:" ::;:'~:~,:~:
SEAL SIGNATURE ~/ _. ;~~;':'__G:':~~~ DATE 0211~
MAILING ADDR S"" , AM
~ MiddebllRh Rrl, ~ppi~fal~. ~TA~90 PM 02 16 2006 04 16 2006
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
@
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28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUNTY "Ten.
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND ~CIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY ~I&'r ~~~J:,u.L
~
SIGNATURE ~