Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
156
o
m
a.n
N
..-
~
....
~
~
::eEl
w
m-
(I)
1
~
!
.t
I
J
-6
I
.I!
i-
ll!!-
~
Ul
w
a:
o
o
<(
>-
IL
U
W
0..
Ul
zr.z
~~g w
~~;5 I-
>-ffiz oct
g]dm (J
~~~ u::
z- -
6~~ I-
:tOUl IX:
0>->- W
Ujti5C3 (J
b~lO
Z::i~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas J. Kelly, Jr.
FIRST MIDDLE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge 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 th~ state. II ,-~ ~ I
21 SIGNATURE OF GROOM ~ .fN{,..S v-rat2CZ 'i/72.. 22. SIGNATURE OF BRIDE ~ Jl..)..a/L(! In ~d7.{)#~
,4U..::,zR; ~ - USE CURRENT NAME 12127/2005
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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) John " asterson
SEAL SIGNATURE ~ ~'! ~.- .=::-" DATE 12127/2005 TIME MONTH YEAR MONTH DAY
'-v-' MA~5G~~dr~b sh Rd, Wappinger Falls, NY 12590 12:45~~ 12 28 2005 02 25 2006
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27;ZTYPE F CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ELlGIOUS 10 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED.
couNrvOutchess
CITYfTOwNWappinger
~~~~~CRT1368
~G~I~J~R156
1. A. FULL NAME
CURRENT SURNAME
"-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEj, 06 64-6831
D. SOCIAL SECURITY NUMBER I -
2 RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY "!"J TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eeDSJe
o STREET ADDRESS 31 Phyllis Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"[] NO
3 A. AGE29 38. DATE OF BIRTH 02 /08 /1976
MONTH DAY YEAR
w
>-
<(
>-
en
4. EMPLOYMENT
A. USUAL OCCUPATION Construction Manager
8. TYPE OF INDUSTRY OR BUSINESS De Vito Builders
5 PLACE OF BIRTH North Tarrytown, New York
(CITY, STATE/COUNTRY IF NOT USA)
~
:;
oct
C
w -
<ou.
5u.
~oct
z
;;;
o
t:
>-
>-
6
6. FATHER
A. NAME Thomas James Kellv
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Harriet A. Turner
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
(2) 0 DEATH
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
a:
w
lJ)
:2
:J
Z
o
z
<(
>-
w
w
a:
>-
Ul
w
en
z
w
(J
:J
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Diane Marie Flower
FIRST MIDDLE
~
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kelly
(OPTIONAL. SEE REVERSE119-7 4-0724
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANew York B. Dutchess
(STATE) 'II!. (COUNTY)
C. CHECK ONE Q CITY U TOWN 0 VILLAGE
~~~ClFyPougtiKeepSle
D. STREET ADDRESSj 1 t-'nYllts Road
12590
ZIP "
E. is RESIDENCE WiTHIN LIMITS DF CITY OR INCDRPDRATED VILLAGE? 0 1~r.hl NO
13 A. AGE24 13.8. DATE OF BIRTH 06 14 ~
MONTH DAY YEAR
14. EMPLOYMENT
Nurse
A. USUAL OCCUPATION V B U -it I
assar ros. nOSp a
8. TYPE OF IND~IRY OR fJjsWis~ew Y orf(
15. PLACE OF BIRTH ens a ,
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME John Frank Flower, Jr.
8. COUNTRY OF BIRTHU ~ A
17. MOTHER Id
A. MAIDEN NAME Laura Nell Herbo
8. COUNTRY OF BIRTHU S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL A~ULMENT
D~TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
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
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUN~7Ct'~b
9 0 OTHER, SPECIFY
TITLE
DATE
/tA
I(.c. P!2IBr"'
,-c;.. /30 /~~t"
,
I ~'7J 0
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~AGE OF
SPECIFY WM'(tV6€'~S fitu..s.
"'TE ZIP
31. WITNESS TO CEREMONY
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT) NAME (PRINT)
SIGNATURE ~