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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c~ 1368
~~~'~J~R 117
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jonathan M Shufelt
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
(1(l/1( q ~ j 3 il.
-'dl/I J.t) ,
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Karoline L. Shott
MIDDLE CURRENT SURNAME
~
1 A. FULL NAME
11. A. FULL NAME
FIRST
a.
N
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Shott
D. SJ~'~~'~~;ULR;T~E;U~~~~RSE) 111-72-8884
12. RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinoer
D. STREET ADDRESS 25 0 Surry Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES t1 NO
13. A. AGE :10 13.8. DATE OF BIRTH 06 /14 /'\97?
MONTH DAY YEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 082 72 2199
o SOCIAL SECURITY NUMBER --
2 RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY /!1 TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 25 D Surry Lane
ZIP 12590
DYES l"i NO
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A. AGE :10 38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Formula Equipment
5. PLACE OF BIRTH Albanv, New Yark
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Registered Nurse
8. TYPE OF INDUSTRY OR BUSINESS Hudson Valley Hasp. Cntr.
15 PLACE OF BIRTH Mt. Kisco, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
16. FATHER
A. NAME Richard Shott
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Susan Ebersole
8. COUNTRY OF BIRTH USA
1 B, 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. NAME Rainey Shufelt
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Bonnie Bodine
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?
(3) 0 ANNULMENT
./ /
(2) 0 DEATH
8. 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
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21. SIGNATURE OF GROOM"
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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 or subsequent ceremony.
~ 24 TOWN OR CITY CLE.RK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) GlOria .
{TIME MONTH
SEAL SIGNATURE" ATE 07/31/2002
'-v-I ~T~~"tJfim ails, NS~ATE12590 ZIP 01:10~~ 08
I CERTIFY THAT I SOLEMNIZED 27, TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
DATE
by New York Domestic
o ~ RELIGIOUS
O;;L 9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY ~
10 CIVIL
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY 51'" 1f/l-"rS@c12..h.
NAME (PRINT)
SIGNATURE ..
DOH-9B (11/98)
NAME (PRINT)
SIGNATURE ..