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COUNTY Dutchess
CITYITOWN Wappinaer
DISTRICT ,. ':rbO
NUMBER ,;JQQ
~5~~J~R 31
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin Albert VVillis
MIDDLE CURRENT SURNAME
~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
1. A FUll NAME
FROM THE BRIDE
Unda Marie Downina
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Me Clav
c. SURNAME AFTER MARRIAGE V'Jillis
(OPTIONAL - SEE REVERSE) no" "2 8876
D. SOCIAL SECURITY NUMBER U~-
12. RESIDENCE A. New York: B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY lY'TOWN 0 VILLAGE
AND Wa "
SPECIFY DDlnger
D. STREET ADDRESS 25 Mlna Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r! NO
13. A. AGE ~Q 13.B. DATE OF BIRTH Of) /OQ AQR~
MONTH DAY YEAR
FIRST
11. A. FULL NAME
n.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) Q58..C" C59D
D. SOCIAL SECURITY NUMBER _~_
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!I' TOWN 0 VILLAGE
AND Wa"
SPECIFY DDlnoer
D. STREET ADDRESS 25 Mine Drive ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!! NO
M /~1 /1QRR
MONTH DAY YEAR
I
3. A. AGE :4\
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION steam Fitter
B. TYPE OF INDUSTRY OR BUSINESS Locaf 21
5. PLACE OF BIRTH Carmel. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NANE Albert George \Mllis
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Vi{giniA .JAAn ~Arnll
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINESS Vir91lls. Stenger. Robets
15. PLACE OF BIRTH Bronx. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME John Edward Me CIQy
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Dnnne MAri~ ~Acl(nw
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 2
B. HOW DID LAST MARRIAGE END?
(2) 0 DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) cJlI'DlVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04 / 09 / 2004
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
~. Pt'Jl9'~81 NY
DEATH
o
DEATH
o
(3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY
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
YEAR
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
Y knowledge and belief that the information I provided is true
o
o
o
(]If'
22. SIGNATURE OF BRIDE
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit' 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
~
{ SEAL }
'-.t-'
NAME (PRINT)
TIME
MONTH
YEAR
AM
ZIP 02:50PM
l~L
05
05
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ONM. TH
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT I t"
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYDGdCtfes.s-
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY Sorr ) /SLv.K.1 ~ L
NAME (PRINT) ,