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COUNTY Dutchess
CITYITmVN Wepplnger
,~~~~~c~ 1368
~5~~J~R 115
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kfa"Ph J. F~. SURNAME
I
5TATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ki~~' A 1(j!Mr SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~\':5N~~~~~t~~e~~SE)FeIlm.A
D. SOCIAL SECURITY NUMBER 085--5&1421
12 RESIDENCEA. N.~oFk B. ~~
C. ~~~CK ONE 0 CITY [l"fOWN 0 VILLAGE
SPECIFY 'Nappinger
D. STREET ADDRESS 14 WRIIIP LlM ZIP 12580
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MJJG / Q;l ~9i7A2
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER D8]"5Br 2950
2 RESIDENCE A~FlWE;todc B. P~esl
C. CHECK ONE 0 CITY l:iIiI'TOWN 0 VILLAGE
AND tA.....
SPECIFY v_ppnger
D. STREET ADDRESS 14 WnM-IP Lene ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 34 3B. DATE OF BIRTH M~ / 2.4
4. EMPLOYMENT
A. USUAL OCCUPATION Cl.8todi8n
B. TYPE OF INDUSTRY OR BUSINESS Wlpp, Cntr1. Sen. CIa
12590
YES ~ NO
/ y1S68
13. A. AGE 31
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION TeaBher
B. TYPE OF INDUSTRY OR BUSINESS V'Japp. CAtF" Sen, Clst.
15. PLACE OF BIRTH -f~~""l..otwrv York'
16. FATHER
5. PLACE Of BIRTH
6. FATHER
A. NAME Kenneth Jesse Feltm8n
B. COUNTRY OF BIRTH USA
7. MOTHER
, A
A
A. NAME TeFF8AGe David KirlaJp
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nine)' 6ussn Klesbye
B. COUNTRY OF BIRTH U S ,A,
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. MAIDEN NAME Maureen P. Ward
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o Q
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that t the best of my knowl dge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my nght to enter into the marri e ....~ /?
21. SIGNATURE OF GROOM. . 22. IGNATUREOFBRIDE. 1f~A~~ tl. Ai:Jd,~
, 'USE CUR NAME I
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK. DATE
This license authorizes the mjrriage in New York State f the bride and groDm named above by any person authorized by New York Domestic
Relations Law 911 to perform r'Prarriage ceremonies within N York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
rt If checked, this license is to be used only for the purpose of a second or subsequent ceremony,
~
{ SEAL }
'-y-I
24. TOWN OR CITY CLERK
NAME (PRINT)
25. A. SOLEMNIZATION PERIOD BEGINS
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH DAY
YEAR MONTH DAY
YEAR
AM
PM
08
29
10 27 2003
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~~kz,(
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~OWN OF 0 VILLAGE OF
SPECIFY~f~ ~~e lr-
29. OFFICIANT
NAME (PRINT)
ZIP
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