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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Stephen J. Bliss
MIDDLE CURRENT SURNAME
COllNTY Dutchess
C1T~fTOWN Wappinger
DISTRICT 1J5a
NUMBER
REGISTER 128
NUMBER
1. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 104-52-1417
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) --.Ji (COUNTY)
C. X~5CKONE Fi ..g ."ITY O-TQWN 0 VILLAGE
SPECIFY 18111011
D. STREET ADDRESS .,111 High". COUrt ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES r::I NO
3. A. AGE 44 3B. DATE OF BIRTH 12 / 03 / 195
MONTH DAY YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
4. EMPLOYMENT
A. USUAL OCCUPATION Loan Officer
5. :~:::~:I~:USlSOug"_~~~:
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME James Elliot Bliss
B. COUNTRY OF BIRTH U 6 A
7. MOTHER
A. MAIDEN NAME Marla Carolyn Barone
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO'BE CIVIL ANNo-MENT
DEATH
o
L 0 SUPPLEMENTAL FILE
~
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(2) 0 DEATH
11. A. FULL NAME
FROM THE BRIDE
Kerry A Tetrault
MIDDLE CURRENT SURNAME
Schelter
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bliss
(OPTIONAL. SEE REVERSE) 11 D5~uCl'll73
D. SOCIAL SECURITY NUMBER D" ~"'UW'
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 ""OWN 0 VILLAGE
~~~CIFY FlBhkill
D. STREET ADDRESS 8111 H1ahrldae Court
ZIP 12590
YES D""NO
A 956
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
13. A. AGE 48 13.B. DATE OF BIRTH CJ7 / OS
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Credentialin9 Coorcinator
B. TYPE OF INDUSTRY OR BUSINESS Care Core National
15. PLACE OF BIRTH Beacon. New' York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Noel Schetter
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Patrlda ~rAltt
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) D~VORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED1 02 / 13 / 2003
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DlIfES D 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
0211312003 Poughkee.psIe. N&w York
DEATH
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YEAR
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNrJ)...rfcJAe.s s
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
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STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
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29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
'fj( CITY OF D TOWN OF 0 VILLA!3E OF
SPECIFYPO U 3 V\ k:.~ 1'e;
31. WITNESS TO CE
NAME (PRINT) S
SIGNATURE ~