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loA. FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
ft4Mmael K. ~ SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FIRST
11. A. FUll NAME FIRST L.atIiK V. KeIl)RRENTSURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~JN~~~t~~O~~SE)"MstIer
D. SOCIAL SECURITY NUMBER 053wfi4.6300
12. RESIDENCE A. NfiIIIIltJ:YDfk B. Qutch,eBB
C. ~gCK ONE 0 CITY D,;ifOWN 0 VILLAGE
SPECIFY \flBppinger
D. STREET ADDRESS 7 l\ Alpine DlWe ZIP 12590
E. IS RESIDENCE WITHIN UMlTS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
13. A. AGE 34 13.B. DATE OF BIRTH tdD / "Ilh ~!181
14. EMPLOYMENT
lL
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
on ~g..5317
2. RESIDENCE A. ~)YClr:k B. ~_
C. ~~gCK ONE 0 CITY Q,iTOWN 0 VILLAGE
SPECIFY lNappinger
D. STREET ADDRESS 7 A Alpine DrWe
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3B. DATE OF BIRTH
ZIP
o
3. A. AGE 40
4. EMPLOYMENT
A. USUAL OCCUPATION lir:9n8.r
B. TYPE OF INDUSTRY OR BUSINESS NoFlhbrook ContraGlAI
5. PLACE OF BIRTH -~~~..:York
6. FATHER
A. USUAL OCCUPATION Ethies Offieer
B. TYPE OF INDUSTRY OR BUSINESSN. Y. Pa-M Authorlt)'
15. PLACE ,OF BIRTH GIftl'caIIIr. Nal~<<k
16. FATHER
A. NAME DcJugI_ GleAR Nestler
B. COUNTRY OF BIRTH U S l\
7. MOTHER
A. MAIDEN NAME Carolyn Merle M' Keown
B. COUNTRY OF BIRTH U S 1-
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRiAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME Jehn dtBeph Kelly
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME
StIsIn Lee Palmer
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 0 0
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
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MaNni, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
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 an
as to my rigllt to enter into the
21. SIGNATURE OF GROOM ~
o 1ST
o 2ND
o 3RD
o 4TH
that the information I provide
o
o
o
o
o
o
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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 51
Relations Law ~11 to perform marriage ceremonies withi 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 ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
omestic
~
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
TIME
MONTH
YEAR
AM
09:40pM 09
18
11 182003
28. PLACE WHERE MARRIAGE OCCURRED
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATI
1M MO.
AM
'3!~PM
W
5 ~=_'l>..u. <~~,<~i.~'
LL SIGNATURE~~Il...-W--__
to- MAILING ADi.'lESS
;;; rr (J( n~ \11\ Sl-. t, S'c.,~Dr'\ I~, ,
W --'STREET ~ITYrrOWN .
o 30. WITNESS TO CE ONY
10 CIVIL
A. STATE NEW YORK B. COUNTY l.tA~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF bi!f TOWN OF 0 VILLAGE OF
SPECIFY ~.",....
NAME (PRINT)
SIGNATURE ~
DOH-98 (11198)
NAME (PRINT)
SIGNATURE ~