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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
KRrI V .Jllhn
FIRST MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY [)Lrt~~
CITYiTOWN Wappinger
~~~~~T 1~8
'~5~I~J~R 1Q
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cmhp-rine M$Jhp-r
FIRST MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SDCIALSECURITY NUMBER 064~74.8~03
2. RESIDENCE A. ~~) York B ~~P'i'-C!.
C. CHECK ONE D CITY o.;rOWN D VILLAGE
AND
SPECIFY WappingP-f
D. STREET ADDRESS 6r. C"el5~ Ritigttt {")rivfiI ZIP 1 ?#)M
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ..I11hfl
(OPTIONAL. SEE REVERSE)
D. SDCIALSECURITYNUMBER 1~?n4-1S1q
12. RESIDENCEA. N(~E~nrk B. ~~~'S
C. CHECK ONE D CITY D ti/OWN D VILLAGE
AND W .
SPECIFY l'IppI"gf!r
D. STREET ADDRESS' Fie;: Chfill~M Rldgt; Drive ZIP
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
MO~j / ;U;l
1'590
YES D~O
/1m;.4
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES cYNO
MoJll / ~1 / y~~7
13. A. AGE 30
14. EMPLOYMENT
13.8. DATE OF BIRTH
3. A AGE 32
4. EMPLOYMENT
38. DATE OF BIRTH
A. USUAL OCCUPATION Phone Technician
8. TYPE OF INDUSTRY OR BUSINESS Verizon
5. PLACE OF BIRTH (~~tw&-M?o;J.I'lnd
6. FATHER
A. USUAL OCCUPATION !=lair DreSlifer
B. TYPE OF INDUSTRY OR BUSINESS Jag Hair Salon
15. PLACE OF BIRTH (~P.~tl!lT~P York
16. FATHER
A NAME \Mlliam John Maher
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Joan Florence EI$ele
B. COUNTRY OF BIRTH U S Ii.
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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A. NAME Karl Heinz Juhn
8. COUNTRY OF BIRTH Ger.many
7. MOTHER
A MAIDEN NAME Mary 0' Connell
8. COUNTRY OF BIRTH Ireland
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
(2) D DEATH
DEATH
o
o
o
(2) D DEATH
o
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B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? 13) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
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
MONTH DAY YEAR
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
o
()
o
D
o
D D 1ST
D D 2ND
D D 3RD
D D 4TH
owledge and belief that the information I provided is tr
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to
as to my right to enter into the marriage
21. SIGNATURE OF GROOM ~
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22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat of
Relations Law !l11 to perform marriage ceremonies within W 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 CITY CLERK, 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Gl9~Jy~ "'~1 ~
SEAL SIGNATURE~ ,/t-\"('~./.IE..Ai;:. 'i DATE n':l"''''ntV\
MAILING ADDRESS ,/ ~ ... .... .r-~'UU
'-.;-I . '/. ,
STRE .. TE
I CERTIFY THAT I SOLEMNIZED 27. TY E OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE RELIGIOUS
DATE AND AT THE TIME AND 3 .
PLACE INDICATEO. .'
~
29 OFFICIANT -:j OJ b
NAME (PRINT)
:at
,c;
DATE 0310112004
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
YEAR
TIME
MONTH
03
02
2
04
30 2004
28. PLACE WHERE MARRIAGE ORCU~ED h ? r
i/ {; I C/ I (;..J-l
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF ~LLAGE OF
/'rhl;)
SPECIFY ~'/- / 'I