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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROQM
JeotJLlarGld \jerw.SURNAME
COUNTY DutchesS
g:~~gWN Wappnger
~~~I~~R 1300
NUM8ER 147
1. A. FUll NAME
FIRST
l1.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIAl SECURITY NUMBER
130-62 7997
B. ~
VILLAGE
2. RESIDENCE A. N,~TE)
C. ~~6CK ONE D CITY CjJTOWN D
SPECIFY Gardflier
D. STREET ADDRESS 115 Has_Lick Road ZIP 125R1
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE? DYES of NO
M~7 / 21 / y1ffl
3. A. AGE 32
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Car=penter
B. TYPE OF INDUSTRY OR BUSINESS K!td:lens By Andr"
5. PLACE OF BIRTH (~g,*-Mltrr~ York
6. FATHER
A. NAME Andre 'Jensbles
B. COUNTRY OF BIRTH US".
MOTHER
A. MAIDEN NAME Eleanor Calourl
B. COUNTRY OF BIRTH U S ^
NUMBER OF THIS MARRIAGE 1
PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) D DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
/
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
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
KallY Ann Keesler
MIDDLE CURRENT SURNAME
.-J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Keesler
(OPTIONAL. SEE REVERSE) 053-~ 0658
D. SDCIAl SECURITY NUMBER' L-
12. RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D~OWN D VILLAGE
AND Wa'
SPECIFY ppnger
D. STREET ADDRESS 1561 Route 376 ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? DYES D" NO
13. A. AGE 31 13.B. DATE OF BIRTH 02 / 16 /1972
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Carmel Cntrl. SchI. [)1st.
15. PLACE OF BIRTH l\I\Ieck. New York
(elM, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME James ThomDBOrl Keesler
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME $I ~n MBty Hannigan
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEAT~
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? 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
D
D
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1ST D D 1ST
2ND D D 2ND
~D D D ~D
~ D D ~
I, being duly sworn, depose and say, that to the best of my knowledge and be ief that the information 1 provided is true an
as to my right to enter into the marriage t
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEF ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
'-..,-I
NAME (PRINT)
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND o\:)
PLACE INDICATED. , \ PM 10 - 9 D OTHER, SPECIFY
W
~ 29 OFFICIANT 0(\/\ Il. I If:'" ~ .J\t\ )..,r n ~ \ ,. t\-\--
<( NAME (PRINT) \ 'C'\.\".''-\ ,G\......... 'V\ 1)'\ ~ l'l...~ TITLE ~ ~ ~ \
~~~a~u ~~:~~~s
w STREET ~ STATE ~
() 30. WITNESS TO CEREMONY 31. WITNESS TO CERE Y
'w V ~~ NAME (PRINT)
SIGNATURE ~
DATE
by New York Domestic
TIME
MONTH
ZIP
AM
01: 1'9
2B. PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
\J\\ ~
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF ~ VILLAGE OF
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