104
"-
N
a;
Lt'>
N
T""
~:i:z
F~g w
~ il' ~ ~c:r:
>-wz
~dai 0
~~~ u:
z-
~~~ i=
[to", a:
0>->- W
w~C5 0
....mLO
~~~
COUNTY Dutchess
CITYfTOWN Wappjnaer
~~J~~CRT 1368
~5~I~J~R 104
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RobertA Tretola
MIDDLE CURRENT SURNAME
I
STATE RLE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
FROM THE BRIDE
Allison B. Kiellander
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Cummings
c. SURNAME AFTER MARRIAGE Tretola
(OPTIONAL - SEE REVERSE) ~f\n OC9834
D. SOCIAL SECURITY NUMBER OUU"'OU"
12. RESIDENCEA. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY r! TOWN D VILLAGE
AND \At .
SPECIFY V wappinger
D. STREET ADDRESS 2 Blackthorn Loop ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
13. A. AGE 21 13.B. DATE OF BIRTH 07 /OS ~B3
'. MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Commission Sales
B. TYPE OF INDUSTRY OR BUSINESS Sears
15. PLACE OF BIRTH Ottawa, Illinois
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Teddy Luke Cummings
B. COUNTRY OF BIRTHU SA
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 133--72-6527
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VIUAGE
~~~CIFY Wa~er
D. STREET ADDRESS 2 Blackthorn Loop ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES ri NO
08 /01 /1980
MONTH DAY YEAR
3. A. AGE 24
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION student
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Yonkers, New' Yark
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
~ A. NAME AndreYI Tretola
> B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gail Elizabeth Hebert
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
17. MOTHER
A. MAIDEN NAME Jennifer Lynn. Kiellander
B. COUNTRY OF BIRTHU S A
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) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? D YES 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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
a;
w
Ol
::l!
~
z
o
z
<
l;;
w
a;
>-
Ul
o 0 1ST D D
D 0 2ND D 0
o 0 3RD D D
o D 4TH D D
y knowledge and belief that the information provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ O. Q! ; l)(\ll \ ~O 0 b ~ \\ 1\,
. LJ US~R~AME
DATE 08l24f2004
by New York Domestic
1ST
2ND
3RD
4TH
I, being duly sworn, depose and s y, hat 0
as to my right to enter into the m . e
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BI;1'ORE ME
SIGNATURE OF TOWN OR CITY C~ERK ~
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.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CIJ:l:ICL~K J M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) \:i ona . orse
{" TIME MONTH YEAR MONTH
SEAL SIGNATtJlfE '
M~~(Bihs AM 08 25 2004 10
'-.,-I 12:14 PM
w
en
z
w
o
::i
YEAR
232004
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT TH
PLACE INDI
ZIP
l~L
28. PLACE WHERE MARRIAGE OCCU~
A. STATE NEW YORK B. couNr(J>fIlfC~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
D CITY OF D TOWN OF cY'VILLAGE OF
SPECIFY t(~lli:h~"i.g ~
NAME (PRINT)
SIGNATURE.
DOH-9B (11/98)
NAME (PRINT)
SIGNATURE.