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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 ~