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i;:OUNTY. Dutchess
CITYfTOWN Wappinger
~~J:~CRT 1368
~5~~J~R 17
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rn~DL!$ImP-tl. ~~~t':~WRNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Qmse T. GO!mRENT SURNAME
~
, . A FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER n7~72.7350
2. RESIDENCE A. ~~E)Vnrlr B. g~ess
C. CHECK ONE 0 CITY [jITOWN 0 VILLAGE
AND
SPECIFY Wappinger
D. STREET ADDRESS 510 ~Alon~ Road Apt A'2ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0
3. A. AGE 32 3B. DATE OF BIRTH MOQ, / Q~
4. EMPLOYMENT
A. USUAL OCCUPATION R~i1
B. TYPE OF INDUSTRY OR BUSINESS Wel Mart
5. PLACE OF BIRTH ~"'&~11Setts
6. FATHER
A. NAME \M1Ii~m PAtri,* Kelbaugh
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME Barbara .4.nn Marlatt
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
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~N~~~~~:~~e~~SE)Kalbaugh
D. SOCIAL SECURITY NUMBER 128--58 8356
12. RESIDENCEA. N~ErQrk B. ~
C. CHECK ONE 0 CITY o"OWN 0 VILLAGE
AND W .
SPECIFY . appmgel"
D. STREET ADDRESS 510 Meloney Road.f\pt. Kl ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Ct' NO
Mo1~ / OS ~9l4
1~
YES ci" NO
/ .;1973
13. A. AGE 30
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Sales .~ociate
B. TYPE OF INDUSTRY OR BUSINESS WaI Mart
15. PLACE OF BIRTH ~.Y YMSA)
16. FATHER
A. NAME Richard Golia
B. COUNTRY OF BIRTH USA.
17. MOTHER
A. MAIDEN NAME Resemar,- Jaoobl
B. COUNTRY OF BIRTH U S p,
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
o
(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
MONTH OA Y 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
0 0 1ST 0 0
0 0 2ND 0 0
0 0 3RD 0 0
0 0
imeJllt exists
by New York Domestic
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{ SEAL }
'-v-'
TIME
MONTH
YEAR MONTH
YEAR
AM
PM
03 15 05 13 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ':b. ,:Jt'. it,<
....
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF'~TOWN OF 0 VILLAGE OF
SPECIFY ()J (vfJ JJ J) It e y'"
. ,I I
ZIP
RELIGIOUS ~VIL
o OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)