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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jon Klaas Levett
MIDDLE . CURRENT SURNAME
COUNTY Dutchess
C1TYITOWN Vvappjnaer
~~J~~~T 1368
~5~~J~R 82
1. A. FULL NAME
FIRST
"-
N
8. BIRTH NAME, IF DIFFERENT
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEI071 CC1648
D. SOCIAL SECURITY NUMBER "'UO"
2 RESIDENCE A. N Y B Dutchess
(STATE). (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY PouqhkeeDSie
D. STREET ADDRESS 44 Lorraine Blvd. ZIP 12603
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
05 /15 /1981
MONTH DAY YEAR
3 A. AGE 23
38. DATE OF BIRTH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Carrie Ann Bushek
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Levett
D. scig~~I~~c~LR;T~E~U~~~~RSE) agO-Sa.. 7066
12. RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!l'TOWN 0 VILLAGE
~~~CIFY WaoPinaer
D. STREET ADDRESS 43 Reaaie Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 22 13.8. DATE OF BIRTH 05. Av.:i 7.9R?
MONTH'~ DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Mt. St. Mary's
15. PLACE OF BIRTH Yonkers. New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Georqe Kenneth Bushek
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Dorothy Mary Downing
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
4. EMPLOYMENT
A. USUAL OCCUPATION Landscaping
B. TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTH Poughkeepsie. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME John Russell Levett
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Annette Carol Vallenga
8. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY 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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say' at 0
as to my right to enter into the mar( ge st.
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
ge and beliel that the mlormallon I provided is true and that I declare that no legal Impediment exists
22 SIGNAT~RE OF BRIDE ~ ~tf 4l~
DATE 0712112004
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
23. SUBSCRIBED AND SWORN.
SIGNATURE OF TOWN ORI ERK ~
This license authorizes the marriage in New York State I the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o "checked, this license is to be used only lor the purpose 01 a second or subsequent ceremony.
~ 24 TOWN OR Clrt CLE;.RK . 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) (.jlona J. Morse
{ () 071"\112004 TIME MONTH YEAR MONTH
SEAL SIGNATU~ . DATE ,&.
--..-- M~'MrCBebush, -nger Falls, NY 12590 09:10 AM 07 22 2004 09 19 2004
STREET CITYITOWN STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o:p( RELIGIOUS
~t;~E ~~glt:T~~E TIME AND 9 0 OTHER, SPECIFY
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3)' 0 ANNULMENT
/ /
(2) 0 DEATH
YEAR
10.CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUN-;;Qt.u-hlle$,~
MONTH DAY 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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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C. L09ATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF }( TOWN OF Q VILLAGE OF
SPECIFY 12A ST "'FI SH 1< I L. '-