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COUNTY Dutchess
CITYITOWN WappinQer
~~~~kc; 1368
~~~'~~~R 70
~ 1 A 11= Ut- NI=W YUHf\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ryan 1. Mc Kechnie
MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
jift(
0~J7-ti 2.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nicole T. Thompson
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
A FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE Mc Kechnie
(OPTIONAL. SEE REVERSE) 122-66-4902
D SOCIAL SECURITY NUMBER
12 RESIDENCE A. New York B. OranQe
(STATE) J (COUNTY)
C CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
~~~CIFY Wallkill
o STREET ADDRESS 16 Dominic Street ZIP 10941
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ti' NO
13 A AGE 23 13.B. DATE OF BIRTH 02 /04 /1979
MONTH DAY YEAR
a.
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEI087_68_4118
o SOCIAL SECURITY NUMBER
2 RESIDENCE A New York B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W '
SPECIFY apPInQer
o STREET ADDRESS 36 Swenson Drive
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A AGE 23 3B. DATE OF BIRTH
ZIP 12590
o YES ~ NO
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Police Officer
B TYPE OF INDUSTRY OR BUSINESS United States Air Force
15. PLACE OF BIRTH Bronx, New York
(CITY. STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A USUAL OCCUPATION Mechanic
B TYPE OF INDUSTRY OR BUSINESS Unemployed
5. PLACE OF BIRTH Mount Kisco, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Edward Me Kechnie
B COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Deborah Magliochetti
B. COUNTRY OF BIRTH USA
B NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
16. FATHER
A NAME Noel Thompson
B. COUNTRY OF BIRTHJamaiea
17 MOTHER
A. MAIDEN NAME Cynthia Shaw
B. COUNTRY OF BIRTH Jamaica
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
(3) D ANNULMENT
/ /
(2) 0 DEATH
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
C DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(SI 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
a:
w
OJ
:2
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a:
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on
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, tha
as to my right to enter into the ma .
21.
o
o
o
o
the best of my knowledge
o 1 ST 0 0
o 2ND 0 0
ODD 0
_<d 4TH 0 0
leI that the information I provided is true and that 1 declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ i.-../? ~ ... /A~..rJ/ ~
USE CURRENT NAME ~
DATE OS/28/2002
W
en
z
W
U
::::i
23 SUBSCRIBED AND ORN T
SIGNATURE OF TOWN OR Y CLERK ~
This license auth . es the marriage in New York Sta the bride and groom named above by any person authorized by New York Domestic
Relations Law 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 only lor the purpose of a second or subsequent ceremony.
~ 24 TOWN OR CITY CLE,RK 25. A SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glona
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
'-..;-/ M~~~~ 01 :33 ~~ 05 29 200 07 27 2002
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
r',
-::I
YEAR
10 CIVIL
28 PLACE WHERE MARRIAGE OCCURRED, JI} _ r:
A. STATE NEW YORK B COUNTY U1J2J1tb
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0
VILLAGE OF
'20
ZIP
31 WITNESS TO CEREMONY
SPECIFY H/1h/tU"tL , NY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
SIGNATURE ~
