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COUNr;Qutchess
CITYfTOWN Wappinger
~~~~~cR1368
~G~I~J~R147
STATE. OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT,. LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Marvin Chamberlin. JR.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
.M/;
q- N - 0 ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Fallon M. Kessler
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE1I29-66-6606
D. SOCIAL SECURITY NUMBER I
2. RESIDENCE A.New York a Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITYwtJ TOWN 0 VilLAGE
AND W .
SPECIFY apPlnaer
D. STREET ADDRESS 1668 Route 9 Apt. F 1 0 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"d NO
3. A. AGE'34 3B. DATE OF BIRTH 11 /20 /1967
MONTH DAY YEAR
13. A. AGE20
13.B. DATE OF BIRTH
08
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTHCarmeJ, New York
(CITY, STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Roofina Contractor
B. TYPE OF INDUSTRY OR BUSINESS Self - Employed
5. PLACE OF BIRTJ::ort lauderdale, Florida
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Edward Kessler
B. COUNTRY OF BIRTM S A
17. MOTHER
A. MAIDEN NAME Dixie Finnev
B. COUNTRY OF BIRTl-f.J S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
6. FATHER
A. NAME Marvin Chamberlin
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kathy Doherty
B. COUNTRY OF BIRTH USA
6. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
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
o
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23. SUBSCRIBED AND SWORN TO BEFORE ME 09/11/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE .
This license authorizes the marriage te of the 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 purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY Cl~RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glon
TIME MONTH
SEAL SIGNATURE ~ -- DATE 09/11/2002
'-.,-I M~Mfciai~bush Rd i er Falls NY 12590
STREET CITYfTOWN TATE
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27~TYP OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ELIGlOUS 10 CIVil
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
W
(J)
z
W
o
:J
YEAR
ZIP 02:05 ~~ 09
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF 0 TOWN OF 0 VilLAGE OF
SPECIFY IIWJ~()~I
ffIoNe: 91./-S:~~ D y~
NAME (PRINT)
SIGNATURE ~
DOH.96 (11/96)
NAME (PRINT)
SIGNATURE ~