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COUNTY Dutchess
CITYfTOWN Wappinger
~~J~~ 1368
~G~lgJ~R 22
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jo~ LLoyd King
MIDD CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Casey L. Andersen
MIDDLE CURRENT SURNAME
1. A. FUll NAME
11. A. FULL NAME
FIRST
FIRST
S. BIRlH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE) 5- 3 6661
D. SOCIAL SECURITY NUMBER 46 9-
2. RESIDENCE A, Nayork B. ~~ess
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
STREET ADDRESS 37 A Sherwood Forest ZIP 12590
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rf NO
11 / 14 /1980
MONTH DAY YEAR
B.. BIRTH NAME (MAlDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kina
(OPTIONAl- SEE REVERSE) 106-62 5933
D. SOCIAL SECURITY NUMBER "-
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cfTOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 3 ~ A Sherwood Forest ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D"" NO
13. A. AGE 23 13.B. DATE OF BIRTH 04 /23 /1979
M~H DAY Y~R
D.
E.
3. A. AGE 2:1
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Forester
B. TYPE OF INDUSTRY OR BUSINESS Environmental Consultants
15. PLACE OF BIRTH Glen Falls. New York
(cnv, STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Iron Worker
B. TYPE OF INDUSTRY OR BUSINESS C & S Wholesale Groc.
5. PLACE OF BIRTH l.nmus l.hnsfi - Texas
(Cnv;-Ji'ATEICOUNTRY IFili5i' USA)
6. FATHER
A. NAME Grady King
B. COUNTRY OF BIRTH t 1 !=i A
7. MOTHER
16. FATHER
A. NAME Martin Andersen
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Rnhin Hill
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
o 0
DEATH
o
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A. MAIDEN NAME Sheny Pa5~fPOr:E."
B. COUNTRY OF BIRTH \ I ~ A
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 n
B. HOW DID LAST MARRIAGE END? (3) c:t'olVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 11 / O~ /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? O...fES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DAle OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
11 f05l2Q02 Minot, North Dakota oJ 0
o 0
o 0
o
ean
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
o
o
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(2) 0 DEATH
7n07
YEAR
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR CITY LERK~ DATE
This license authorizes the marriage in New York S person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used ani ose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
"-v-I
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
YEAR
-
SIGNATURE ~
MAILING ADI:!RESS
AM
12:01'M
03
06
200
05
04 2003
A
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY tffrre.;C
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFV'f1C ll.Iti kYil 1 oIL, "IV_)I
1~CIVIL
mLE c~~'ru~
DATE ? 'a,..: () ..,
/iI. ~ I~J
STATE"
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
ZIP
". WITN"" "'~
NAME (PRINT)
SIGNATURE ~
a. A(\dtZ.r~~
CJ.. ~~