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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
AcIIIrP D. BenrdENT SURNAME
COUNTY Dutchess
CITY/TOWN \&f8pp1nger
DISTRICT ..
~~~~~~R1368
NUMBER 28
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 959-6&-B834
2. RESIDENCE A. ... '" B. .... "'_L ---
1"1 (lITATE) ~
C. ~5CK ONE 0 CITY "TOWN 0 VILLAGE
SPECIFY PaughlcDepBie
D. STREET ADDRESS 12 Artler HII Reed ZIP 12603
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPOFIATED VILLAGE? 0 YES iii NO
MdIa / ts / 1883
3. A. AGE 20
4. EMPLOYMENT
3B. DATE OF BIRTH
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A. USUAL OCCUPATION L.endle8piAg
B. TYPE OF INDUSTRY OR BUSINESS Self empleyed
5. PLACE OF BIRTH Ro"".'.,JlllW York
6. FATHER
A. NAME 08vid Bennett
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME KatherIne Meenagh
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 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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(2) 0 DEATH
(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 Ir:lFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY. IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I'
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
DllYrAM. Fen:a_ENTSURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT .
C. SURNAME AFTER MARRIAGE a-n.....
(OPTIONAL - SEE REVERS~. IVII;
D. SOCIALSECURITYNUMBER 099 72 7613
12. RESIDENCE A. ... V. B. ..... ...._L -II
,. ~TATE) ~~
C. ~~5CK ONE 0 CITY 0 TOWN ~ VILLAGE
SPECIFY VJapping8IB Falls
D. STREET ADDRESS 48.So. Mill... ~ue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? iI YES 0 NO
JMH /211y 191a
13.B. DATE OF BIRTH
13. A. AGE 20
14. EMPLOYMENT
A. USUAL OCCUPATION SeGr8ta1)'
B. TYPE OF INDUSTRY OR BUSINESS K 8 L Corp.
15. PLACE OF BIRTH ~~!II~.rlMIIiIM)
16. FATHER
A. NAME Jam. F8IJ8ntG
B. COUNTRY OF BIRTH USA-
17. MOTHER
A. MAIDEN NAME Je8nne Kelly
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(3) 0 ANNUUMENT (2) 0 DEATH
/ /
MONTH DAY
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
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
YEAR
o 0
o 0
o 0
o 0
iment exists
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1ST
2ND
3RD
4TH
I. being duly sworn, depose and say, t
as to my right to enter into the marri e
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 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.
o If checked, this license is to be used only for the purpose of a second Dr subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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DATE
DATE
by New York Domestic
TIME
MONTH
25. B. SOlEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
MONTH
DAY
YEAR
03I26QQ03
AM
10:16pM 03
Xl
05
25 2003
ZIP
26. SOLEMNIZATION OCCURRED
TIME M. DAY YEAR
AM
M
A
27. TYPE OF CEREMONY
o 1i( RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B. COUNTY j)IJOiISS-S.
C. LOCATIO,,!..OF CEREMONY
(CHECK ONE AND SPECIFY)
.CITY OF 0 TOWN OF Ik'VILLAGE OF '
SPECIFY i.J)iJ(J(lJJV~a-J F4U..s
,
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
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SIGNATURE ~ a ~./h
MAILING ADDRESS t?.n
j)"" O'pNJI./ fj ~.D {JJ1J/'tJif/hF,/lJ ~t.;(
STREET CITY!fOWN '
30. WITNESS TO CEREMONY
29. OFFICIANT
NAME (PRINT)
l JJ P''1 k,1<.
TITLE
DATE (!)4
tv/;.
SATE
28. PLACE WHERE MARRIAGE OCCURRED
PJ)- S rfJR..
d, - 0:3
/2510
NAME (PRINT)
SIGNATURE~