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COUNTvOutchess
CITYfTOWN Wappinaer
~~~~~c~1368
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Keith T. Holle
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
o
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:t; 1 /1
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jami A Clausson
MIDDLE CURRENT SURNAME
~
11 A FULL NAME
FIRST
1 A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Holle
(OPTIONAL - SEE REVERSE068-12 1664
D. SOCIAL SECURITY NUMBER -
12. RESIDENCLl'Jew York BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~cIFWappinger
o STREET ADORESI3 Hamlet Court
ZIP12590
o YES"tJ NO
147~
Y AA
BIRTH NAME. IF OIFFERENT
3. A AG~5
10
MONTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGqf\ 138. DATE OF BIRTH 118 A 6
MONTH DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATIONTeacher
B. TYPE OF INDUSTRY OR BUSINES~appingers Central School
15. PLACE OF BIRTSronx New V-oor!( 0 .
(CITY. StATE/COUNTRY IF NOT USA)
16. FATHER
A NAMEGeoffrey Clausson
B. COUNTRY OF BIRTLl S A
17. MOTHER
A. MAIDEN NAMEOeni~e Golio
B. COUNTRY OF BIRTW S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
4. EMPLOYMENT
A. USUAL OCCUPATION Construction
B TYPE OF INDUSTRY OR BUSINES~rotec
5. PLACE OF BIRTrGoshen New York
(CITY, STAT~/COUNTRY IF NOT USA)
6. FATHER
A. NAME Ronald HoUe
B COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME lC Rthlp.p.n Murphy
8. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
DEATH
o
(2) 0 DEATH
n
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE ENO? (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 0
o 0
o 0
o 0
o legal impediment exists
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
S f my knowledge and belief that the information I provided is true
21 SIGNATURE OF GROOM ~
23.
the bride and groom named above by any person authorized by New York Domestic
w
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TIME
MONTH
YEAR MONTH
YEAR
ATE.08/01/2002
Y 12590
STATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
AM
PM
8
08
2002 10
06 2002
2:42
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK 8. COUNTY bLA+chess
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ft TOWN OF 0 VILLAGE OF
SPECIFY End 0'5 ~ K)'II
10 CIVIL
TITLE KC .~ ,-; <--$ \~
DATE 0//7 / OoZ
I c2.. 5' 3]
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~
31 WITNESS TO C
