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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
EdlNard Dennis Medwiclc
FIRST MIDDLE
COUNTY Dutchess
CITYfTOWN WaDdnaer
~~J~~crJ 1368
~Q~I~J~R 139
1. A. FULL NAME
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)11o-~ anN::
D. SOCIAL SECURITY NUMBER ~vJ
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
~~~CIFY Wa~nger
D. STREET ADDRESS 6H Alpine DrIve ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
08 /04 /1958
MONTH DAY YEAR
3. A. AGE 47
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Correction Officer
B. TYPE OF INDUSTRY OR BUSINESS Flshklll Correctional
5. PLACE OF BIRTH Yonkers. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Jaseph John Mec.Wck
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Eleenor Evelyn Kellman
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT DEATH
200
B. HOW PID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12 / 28 /2000
MONTlIl DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? I:I YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED . AGAINST WHOM
~~H, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST utif18f1993 PouahkBeDsle. NM York ~
2ND 12f.2B12OOO Poughkeepsie, New York ~
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Keely Ann R7Abo - Odell
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT St7Abo
C. SURNAME AFTER MARRIAGE Medwick
(OPTIONAL - SEE REVERSE)091 ~A0628
D. SOCIAL SECURITY NUMBER --~
12. RESIDENCE A.NAw York B. Dutchess
L~.x~h*) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Rhinebeck
D. STREET ADDRESs2 Beacham Roed
-.J
CURRENT SURNAME
ZIP 12572
o YES~ NO
197Q"R
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE~'i 13.B. DATE OF BIRTH ()Q ~
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Nail Technician
B. TYPE OF INDUSTRY OR BUSINESS Tip To Toes o.y Spa
15. PLACE OF BIRTHPftufthlMAMie. New York
. ((!j~~Mlrc~~y IF NOT USA)
16. FATHER
A. NAME Robert Charles !bAbe
B. COUNTRY OF BIRT~ SA
17. MOTHER
A. MAIDEN NAME Donna MElrlol'l GO'IAI'
B. COUNTRY OF BIRT~ S A
1 B. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 08 /2005
MONTtItI DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ 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) SELIF SPOUSE
1ST 07/1411999 Poughkee.psle. NewYorkM
2ND 09I0BI2005 Poughkeepsie. New York ~
DEATH
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of the bride and groom named above by any person authorized by New York Domestic
W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
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STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
STREET CITYfTOWN
30. WITNESS TO SEREMONY n
NAME (PRINT) ~'2 ~ 60
SIGNATURE~ ~
DOH-9B (11198)
TIME
MONTH
YEAR MONTH
YEAR
ZIP
AM 11
.02 PM
18 2005 01 162008
~L
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couN~---kL~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF &OWN OF 0 VilLAGE OF
ZIP
31. WITNESS TO ~NY
"'.'1'''''' . ~'Uo.\I(\
SIGNATURE~