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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1. A. FULL NAME JeIJMine Le \./GPublin
1ST 0 0 1ST 0 0
----.......---.-. .,.__._.,-~.,._.,."_._--,-_. - .-----. .' .,~
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~H 0 0 ~H 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 a d that I declare that no legal impediment exists
as to my right to' enter into the . age state.
21. SIGNATURE OF GROOM ~ NATURE OF BRIDE ~
COUNT{)utehess
CITYrrOWN"a,pingeF
DISTRICT ·
NUMeE~68
REG 1ST
NUMBER 119
CURRENT SURNAME
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 056 5& 7322
2. RESIDENCE ANewr~rk B. D~SI
C. ~~6CK ONE ..,0 CITY 0 TOWN 0 VILLAGE
SPECIFY Paughkeepsie
D. STREETADDRE~5 Gerald D~ ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
aH ~iAY ~il~
3. A. AG'29
4. EMPLOYMENT
3B. DATE OF BIRTH
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A. USUAL OCCUPATION Court OtIicer
B. TYPE OF INDUSTRY OR BUSINESsRocklanrl Fam
5. PLACE OF BIRTf6.~~F YO~A)
6. FATHER
A. NAME EveF8lt Le \}em Dublin
B. COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME OaFS JeaR Scott
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
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DEATH
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(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFClRMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
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(THIS SPACE FOR STATE USE ONLY)
". A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAt,IISt8C~ Terese Kelly
FIR T MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGDublin
(OPTIONAL. SEE REVERSIilo 8-58-5449
D. SOCIAL SECURITY NUMBER u6
12. RESIDENCE,NP.W V ork sOutchess
- -(STtTri (COUNTY)
C. CHECK ONE 0 CITYwtJ TOWN 0 VILLAGE
ANOn hk .
SPECIFr:Oug eeDSle
D. STREET ADDRES~3 AnthOny Drive Apt. C308
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o YES 0 NO
1911
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG64 13.B. DATE OF BIRTH 02 't3
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATIO,.,correclion Officer
B. TYPE OF INDUSTRY OR BUSINESf:ishkill Corr. FacllllY
15. PLACE OF BIRT.eOrl Chester. New York
(CITY. STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAMEaJames KellY
B. COUNTRY OF BIRTA.! S A
17. MOTHER
A. MAIDEN NAMESandra Arnold
B. COUNTRY OF BIRT~ S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DifTH
B. HOW 010 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
23. SUBSCRIBED AND SWOR BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat . f the bride and groom named above by any
Relations Law ~11to perform marriage ceremonies within w 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
DATE 09/2212005
NY 12590
STA E
27. TYPE OF CEREMONY
o ~ RELIGIOUS
[~ OTHER. SPECIFY
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NAME (PRINT)
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
12:11 ~~ 09
2005
11
21 2005
23
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYnl),Tr.$~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ITY OF,-R TOWN OF 0 VILLAGE OF
SPECIFY -=tQl)Gtf KL~f51 G'
TITLE BA-PT Ib.T fI.4 I III /STe<
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29. OFFICIANT
NAME (PRINT)