090
0-
N
f-
Z
W
Ul
W
lD
o
-'
::>
o
:t:
Ul
Z
o
~
<
II:
f-
!!l .
Cl
W
II:
W
Cl
<
~
II:
<
::;
u.
o
W
~
()
u:
~
II:
W
()
W
II:
W
:t:
~
Ul
Ul
W
II:
o
o
<
>-
u.
C3
W
0-
Ul
....
:>
~
c
u::
WI.L
~~
~:i:z
i=~~ w
:J!~1!! ....
f-WZ ~
~d~ ()
~~g u::
z-
G~~ t=
[tOUl ~
Of->- W
U,jtM<5 ()
~mLn
~~;o
COUNT1f Dutchess
CITYn-OWN Wappinger
~~J~kc: 1388
~5~I~J~R 90
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael J KelIu IR
MIDDLE ~c\JRRENT SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
SUsaI1 T BebDe!ll
MIDDLE - CUflllENT SURNAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SDCIAL SECURITY NUMBER 07o...R?811 Q
2. RESIDENCE A. NP-W York B. n. JtI"hP-!IR
~) ~
C. CHECK ONE 0 CITY []iI'TOWN 0 VILLAGE
AND Wa'
SPECIFY ppnger
D. STREET ADDRESS 84 Kretch Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!I NO
3. A. AGE 36 3B. DATE OF BIRTH MoW / ~ / y1i65
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~~J~~~~~~~e~~SE)Kelly
D. SOCIAL SECURITY NUMBER 087.72-3223
12. RESIDENCEA. ~lork B. q~.
C. CHECK ONE 0 CITY CJljIII'OWN 0 VILLAGE
AND 'AI.. .
SPECIFY v_ppf'lgP-r
D. STREET ADDRESS 84 I(r"~ Clrt'Je
ZIP 12590
YES C!Il' NO
/.i ~Ei
4. EMPLOYMENT
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13.. A. AGE 28 13.B. DATE OF BIRTH M~ / \1
14. EMPLOYMENT
A. USUAL OCCUPATION RaIP.R.
B. TYPE OF INDUSTRY OR BUSINESS
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS CoMoIldAtAd lllmbAr'
5. PLACE OF BIRTH OueeM New York
(CITY, STATElCl!UNTRY IF NOT USA)
6. FATHER
A. NAME Michael James Kelly
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Rose Mlde SIIerno
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
15. PLACE OF BIRTH
16. FATHER
A. NAME I ennArd ~hn~
B. COUNTRY OF BIRTH l J S A
17. MOTHER
A. MAIDEN NAME Michele Uecker
B. COUNTRY OF BIF;lTH USA
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~D1VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE'ENDED? 09/ 30 / ~
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE{S) ALIVE? ~ES 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
1ST ~Pm9'~I~Yorlt
2ND
3RD
DEATH
DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05 / ')') / ~3
MONTH Dr ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? c:JIIfES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STAlE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0512212OO3 Gosbeft. ~.\t York 0
~D 0
3RD 0
o
o
o
21. SIGNATURE OF GROOM ~
w
en
z
w
()
::::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta
Relations Law ~11 to perform marriage ceremonies within ew 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) GI
TIME MONTH
SEAL SIGNATURE ~ --,
'-.-I MA~~f&jS 09:29AM 08
STREET ZIP PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
by New York Domestic
1~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY '""J) l{ I~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ OF 0 VILLAGE OF
SPECIFY i6 ""'- 6 J/- t:€. ifSt-€-
SIGNATURE ~
DOH-98 (11I9B)
SIGNATURE ~ /"