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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Edwin K. Keeler
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITY/TOWN Wappinger
~~J:kc~ 1368
~5~~l~R 111
1. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 n01 00786
D. SOCIAL SECURITY NUMBER ~ ~--
2. RESIDENCE A. N Y B. 01 Jt,..J\ess
(STATE) (~
C. CHECK ONE 0 CITY ~ TOWN 0 VILlAGE
AND W .
SPECIFY aDDlnaer
D. STREET ADDRESS 47 Uss Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rl NO
3. A. AGE 7Q 3B. DATE OF BIRTH 10 /?Q /1Q?4
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Retired
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Brooklvn. New York
(CITY, STAfElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Victor E. Keeler
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Edith Owen
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 02 / 20 / 1952
M~ D~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
02120/1952 st. PetersburQ. ROOda r:J
DEATH
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NAME (PRINT)
SIGNATURE ~ ·
DOH-98 (11/98)
.0:>>."'11: riLe nUMDcn
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME FIRST LUSYoD~lIe HaynC~ENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Le\Nis
C. SURNAME AFTER MARRIAGE H~nes- Keeler
(OPTIONAL - SEE REVERSE) 271 ~4254
D. SOCIAL SECURITY NUMBER _ ~~__
12. RESIDENCE A. N lTATEl B. D~-!tH!lverss
c. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFY WaDDinaer
D. STREET ADDRESS 47 Uss Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/07 ~?7
DAY YEAR
13. A. AGE 7R
11
MONTH
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Retired
-II
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Franklin Co.. Ohio
(CITY, ST A TElCOUNTRY IF NOT USA)
16. FATHER
A. NAME Milford Lewis
B. COUNTRY OF BIRTH USA
..
17. MOTHER
A. MAIDEN NAME Sadie Rose
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
o 0
DEATH
1
(3) 0 ANNULMENT (2) rfDEATH
/1974
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED? 09 / 19
MONTH ~AY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES r:J 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
AM 09
03:20 PM
ZIP
1~L
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~\l.1C.~
C.