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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
nnnAI~,;::m8. Ken~~1 sJ~NAME
COUNTY Dutchess
CITYITOWN Wappinger
~~J~~CRT 1388
~5~~J~R 18
1. A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 11 JI ~ JI ~1 n"'
D. SOCIAL SECURITY NUMBER _ _~::!_"";L
2. RESIDENCE Pc N(XTE) B. ~~
C. CHECK ONE 0 CITY IY'TOWN 0 VILLAGE
~~~CIFY M~brDOk
D. STREET ADDRESS 202 Greening Place ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 37 38. DATE OF BIRTH M~ / 3R
4. EMPLOYMENT
A, USUAL OCCUPATION I ~ntt.r.Aper
B. TYPE OF INDUSTRY OR BUSINESS Self Empl~Ad
5. PLACE OF BIRTH Pout'lhlMA"'~ NAw V ork
(CITY, !fI'A"TEICOU~IF NOT USA)
6. FATHER
A. NAME nnnAld .Jam8. Kennec\f. Sr
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Theresa Mary Amedeo
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
2 0 0
B. HOW DID LAsT MARRIAGE END? (3) lY'DlVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 02 / M /?M4
MONTH Dr ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? c:J'\-ES 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
07W1998 Poughkeepsie. NY rY 0
0?1n5OOO4 Pnllgt1~e. N v 0 r:!I
o 0
12543
YES ~ NO
/~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
, 1. A. FULL NAME . J~nnifer . J~n T erezis
FIRST MIDDUE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Febbie
c. s~~~~:~M~~~~t~~e~~~nedy
D. SOCIAL SECURITY NUMBER 078-"-6427
12. RESIDENCE A. N ~ATE) B. q[~
C. CHECK ONE 0 CITY []frOWN 0 VILLAGE
AND
SPECIFY M~hrnnK
D. STREET ADDRESS 2l!2 GrAAnlng P1AM ZIP 12543
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13.A. AGE 33 13.B.DATEOFBIRTH Mc1A /~ -1~l2
14. EMPLOYMENT
A. USUAL OCCUPATION SaJ~ MAna~r
B. TYPE OF INDUSTRY OR BUSINESS Kay's JelNeIerJ
15. PLACE OF BIRTH ~~IF ~ ~SA)
16. FATHER
A. NAME Mi.cl\9eJ ,JrRP.ph Febbie
B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME SaAdra Lee Kellemouse
B. COUNTRY OF BIRTH II S A.
1B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) []Wlt,IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04 /?n / ')NV\
MONTH ~ ~
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
1 ST 04I2012OOO Ora~ County, NY 01 0
2ND 0 0
3RD 0 0
o 0
and that I declare that no legal impediment exists
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23. SUBSCRIBED AND SWORN T EFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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 O'::'TY e 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
MONTH DAY YEAR
SEAL SIGNAT~
MAILING ADD
'-v-I .
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED. : 0 0 PM
~~~t~~~~~T FJIe.n .HI J.bSCl{\
SIGNATU ~ GJ.-L .....
MAILING ~ r
:J) '1 I VLI +ILl' 1Z.tJaL:I LVa.-1ck.VL. IN 1..1
STREET;;J CITYITOWN' -+
30. WITNESS TO CEREMONY
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by New York Domestic
MONTH
YEAR
03
05
15 2005
17
SATE
27. TYPE OF CEREMONY
o & RELIGIOUS
9 0 OTHER, SPECIFY
TITL~~~
DATE ~ \ 2..4 \ (~':'l
12S}~ L~
STATE
~c; 05
NAME (PRINT)
SIGNATURE. -:::,.
DOH-9B (11I9B)
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK 8. COUNTY lJI/rCIIE55
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ts" TOWN OF 0
VILLAGE OF
SPECIFY LI,)II3.p{'\ ~ .---c--
SIGNATURE.