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COIINTY DutchesS
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DISTRICT 1
NUMBER
REGISTER 1
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael G. Jutt
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Stephanie A. \MIite
MIDDLE
1. A. FULL NAME
, 1. A. FULL NAME
FIRST
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 114-74-3862
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. New York B. Dutchess
(STATE).J (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 6 HemlOck court
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Jult
(OPTIONAL - SEE REVERSE) 054-82-8429
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B Dutchess
(STATE).Ji (COUNTY)
C. CHECK ON~ 1iI CITY [T TOWN 0 VILLAGE
AND . haft I
SPECIFY IS N
D STREET ADDRESS e HemlOCK Court ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!!f NO
04 /23 )1'980
OAY
3. A. AGE 24
ZIP 12~4
YES r5 NO
/1980
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION veterinary Technologist
15. :~::~~:I~:HUSGrtE~e~::er vetennary HOSp.
(CITY. STATElCOUNTRY IF NOT USA)
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE? 0
04 /21
OAY
13. A. AGE 24
13.B. DATE OF BIRTH
MONTH
YEAR
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Software E~eer
8. TYPE OF INDUSTRY OR BUSINESS l. B. M.
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME VVilliam Edwin Jutt
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Arlene MalY Kenny
8. 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
16. FATHER
A. NAME VVilliam George \MIite
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Anna Hotz
B. COUNTRY OF BIRTH Siovakia
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
(2) 0 DEATH
MONTH OA Y 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, STATElCOUNTRY, 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:
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o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
st of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
2 SIGNATURE OF BRIDE ~
!lrt~~ f.l . lUtL"Jt
, USE CURRENT NAME
DATE 0110312OO5
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within Ne 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 CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) . GI. ona J TIME MONTH
SEAL SIGNATURE ~ . -'
'-y-I MAI~ fJirctiebush R AM 01
STREET STATE ZIP 01 :45PM
I CERTIFY THAT I SOLEMNIZED 27~TYP F CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
YEAR
by New York Domestic
28. PLACE WHERE MARRIAGE OCCURR~ . .
A. STATE NEW YORK B. couN~IIv7Cifr?>S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 .TOWN OF ~r; OF
. I.
SPECIFY !Jf; 1tPI/~6e( s 1tLL.-'
29. OFFICIANT
NAME (PRINT)
~, C, fe'e:,-r
i/;S/aS-
(
/~O
ZIP
31. WITNESS TO CEREMONY
\
TITLE
NAME (PRINT)
SIGNATURE~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~