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COUNTf Dutchess
CITYITOWN \NWnger
~~~kc~ 1388
~5~I~J~R 80
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard HalbriIler
MIDDlE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
11. A. FULL NAME
FIRST
FROM THE BRIDE
Sulan C. Kelly
MIDDLE CURRENT SURNAME
FISher
FIRST
Q.
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE KeIy
(OPTIONAl- SEE REVERSE) 11V\ ....-..982
D. SOCIAL SECURITY NUMBER ~
12. RESIDENCE A. New York B. DutcheII&
(STAlE) ~ (COUNTY)
C. CHECK ONE 0 CITY 0 .,.OWN 0 VILLAGE
;~CIFY p~
D. STREET ADDRESS 24 HoneY LIne ZIP 125S0
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES 0 ~o
13. A. AGE 50 13.B. DATE OF BIRTH 11 / 02 /1952
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION R~ Nurse
B. TYPE OF INDUSTRY OR BUSINESS Vassar BrotherS
15. PLACE OF BIRTH PhllldelDhla. Pennsvvanle
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME Thorn- Me Cutcheon FISher
B. COUNTRY OF BIRTH USA
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE) .-s: "Y'II ru::'!aft
O. SOCIAL SECURITY NUMBER ~~.~
2. RESIDENCE A. Nf!!W Yark B. nlJtcheIIA
(Mmj (~
C. CHECK ONE 0 CITY DwtOWN 0 VILLAGE
AND p'''' .....a.-i
SPECIFY ~.--.-.e
24 Honey L8ne
O. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIllAGE?
3. A. AGE 63 3B. DATE OF BIRTH
ZIP 12590
o YES D.-'NO
...
4. EMPLOYMENT
A. USUAL OCCUPATION Seniar Technician
B. TYPE OF INDUSTRY OR BUSINESS Can Edson
5. PLACE OF BIRTH WAnhMtal:'. New VarIc:
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME
~
~
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u.
<C
\/ifV!Mlt I-IaIbriIter
USA
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 tlI'VORCE (3) 0 ANN\JLMENT
C. DATE LAST MARRIAGE ENDED? 1 y' 14 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) AUVE? 0 'fits 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
11114.11.... PN....... NAwVMr 0" 1ST
o 2ND
o 3RD
o 4TH
be Ie t att e information
AMe SMith
USA
~
17. MOTHER
A. MAIDEN NAME "I~ I I'd.... Luk8
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
1=
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 ~ORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 04/ 12 /
MONTH ~ DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 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
D4I1211IM ~I NewVork 0 0 .;
o 0
o 0
o 0
that I declare that no legal Impediment exists
22. SIGNATURE OF BRIDE ~ -"44.-- /C b /~~
USE CURRENT NAhtE
23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the pu se of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DEATH
o
DEATH
o
(2) 0 DEATH
1994
YEAR
(2) 0 DEATH
199Q .
YEAR
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1ST
2ND
3RD
4TH
I, being dUly swom, epose an
as to my right to enter Into the
21. SIGNATURE OF GROOM ~
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{ SEAL }
'-..-'
YEAR
TIME
MONTH
NAME (PRINT)
SIGNATURE ~ -
MAILING ADD~ESS
09:54'A
PM
05
A
V. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~(J~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF XTOWN OF 0 VILLAGE OF
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
~IVll
29. OFFICIANT
NAME (PRINT)
SPECIFY
NAME (PRINT)
SIGNATURE ~