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COUNTY Dutchess
CITYITOWN Wappinger
~~J~~1J 1368
~5~lgJ~R 163
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert C. Shilkunas
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
~
I~ - 3 J.tl~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Maureen Stewart
1. A. FUll NAME
11. A. FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAMEAFTERMARRIAGE Shilkunas
(OPTIONAl. SEE REVERSE) 084-72 -8436
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA.New York B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE h1 CITY 0 TOWN 0 VILLAGE
~~CIFY FishkJlI
D. STREETADDREss3f Greennlll Urlve ZIP 12024
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
13. A. AGE 29 13.B. DATE OF BIRTH 05 /31 /1973
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSElr\73 66 5678
D. SOCIAL SECURITY NUMBER 'V - -
2. RESIDENCE A. N Y B. Dutchess
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Poughkeegsie
D. STREET ADDRESS 31 C Hudson Harbour Drive ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tl NO
02 /22 / 1974
MONTH DAY YEAR
3. A. AGE 28
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Astor
15. PLACE OF BIRTH Carmel, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME George R. stewart
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Agnes Murphy
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DE8TH
4. EMPLOYMENT
A. USUAL OCCUPATION Route Salesman
B. TYPE OF INDUSTRY OR BUSINESS Poland Spnng
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Robert A. Shilkunas
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Susan Sartauskas
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
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
o
ent exists
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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 Df the bride and groom named above by any person authorized
Relations Law ~11 to perfDrm 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 purpDse of a second Dr subse uent ceremony.
~ 24. TOWN OR CIn',CLE,RK J M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) (,:i ona. orse
{SEAL SIGNATURE ~ ATE 10/03/2002
'-v-I M~'1'Jl~8'Cffifuush Rd, ails, NY 12590
T EET ZIP
~~~R~~RT~~~ IJO~~~N~ZEE~ 26. SOLEMNIZATION
SONS NAMED ABOVE ON THE IME M .
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE
by New York Domestic
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YEAR
A
27. TYJE OF CEREMONY
o Iiif RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY ErHf !1shK111
I/:tX) 10 /9 /)~
29. OFFICIANT ,1)~ ~o ~ ..8t I \1'1 , t
::::::T~ ~IiIAJ. s;kJI1O/- -;;;/MI
MRSErc~5TLE HI/..(/ Iti/c-. 8fOlV X
STREET CITYfTOWN
30. WITNESS TO rE}lEM~NY
NAME (PRINT) V 0.. 't'\ C-\
TITLE ~.C. PRIE;ST
DATE /0//9/ oa.
I '
NY /DLffp'J.
STATE
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~