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J COUNTY Dutchess
CITYfTOWN Wappinger
1368
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DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin L. Hill
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Czama A. Donohue
MIDDLE CURRENT SURNAME
1. A, FULL NAME
11. A, FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 302 80-3352
D. SOCIAL SECURITY NUMBER -
2. RESIDENCE A. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECK ONE 0 CITY D..,.OWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS P.O. Box 936
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 21 3B. DATE OF BIRTH
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hill
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 118-64-2016
12, RESIDENCE A, New York B, Dutchess
(~) ~oo~
C. CHECK ONE 0 CITY 0 "I'bWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS POBox Q36 ZIP 12SQn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 "'f.lo
13. A. AGE 22 13.B. DATE OF BIRTH in / 1R /1QRD
~~ D"A'r ~
ZIP 12590
DYES D"'NO
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Fast Food Manager
B. TYPE OF INDUSTRY OR BUSINESS Wen~s
5. PLACE OF BIRTH Cincinnatti.. Ohio
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Linton Hill
B. COUNTRY OF BIRTH USA
7, MOTHER
A. MAIDEN NAME Marilyn Ri~htp.r
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
A. USUAL OCCUPATION Retail
B. TYPE OF INDUSTRY OR BUSINESS Rnh ~nrP.!C
15. PLACE OF BIRTH Putnam ~nuntv Np.w Ynrjr
(CITY, STATE/COUNTRY I~\ISA)
16. FATHER
A. NAME Jeffery Oonohllf!
B. COUNTRY OF BIRTH II ~ A
17. MOTHER
A. MAIDEN NAME luann Barker
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
DEATH
o
(2) 0 DEATH
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
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
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
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
W
en
z
W
()
::i
o 1ST 0 0
o 2ND 0 0
o ~D 0 0
o 4TH 0 0
lief that the information I provi ed is true and t at I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ ~A.ni~fLUL.
USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~ DATE f14.I7Q/2003
This license authorizes the marriage te of t e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say,
as to my right to enter into the marri
o
o
o
o
my knowledge and
21. SIGNATURE OF GROOM ~
~
{ SEAL }
'-..-'
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
SIGNATURE ~-
MAl B 0 R
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
11 :1 fM
PM
04
200
06
28 2003
30
IP
STA
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
C
26. SOLEMNIZATION OCCURRED
IME MO. DAY YEAR
1,g'CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~(~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
'\ .
SPECIFY tJJ('l--~r I ~e ~,
/(p
03
29. OFFICIANT
NAME (PRINT)
SIGNATURE ~
DOH-9B 11119B\
NAME (PRINT)
SIGNATURE ~