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STATE OF NEW YUHK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Adam L. Feller
MIDDLE CURRENT SURNAME
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 911 to perlorm 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY Dutchess
CITY/TOWN Wappinger
8~~~~~T 13n8
~5~~J~R ?n
1 A. FULL NAME
FIRST
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N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 6 1 008
D SOCIAL SECURITY NUMBER 091- 6-
2 RESIDENCE A N Y B Dutchess
(STATE) (COUNTY)
C CHECK ONE C CITY 0 TOWN l"I VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 4 Roy Avenue. Apt. 2
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
08/
MONTH
ZIP 12590
d'" YES 0 NO
26 / 196
DAY YEAR
3 A. AGE 34
3B. DATE OF BIRTH
4. EMPLOYMENT
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A. USUAL OCCUPATION Truck Driver
B. TYPE OF INDUSTRY OR BUSINESS Metro North
5. PLACE OF BIRTH Manhattan1 New York
(CITY. STATE/COUNTHY IF NOT USA)
6. FATHER
A NAME .1?lY Feller
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME SIIS;;:ln Wpil=:hllch
B. COUNTRY OF BIRTH l J 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
o
;:
Q
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
DA TE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
ffi
ell
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to th
as to my right to enter into the marriage sta ';?
. ...
21. SIGNATURE OF GROOM ~
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{ SEAL }
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NAME (PRINT)
.;J I '"" I;;. rILe. '''VIII'IOLn
(THIS SPACE FOR STA TE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Betsy E. Keith
--1
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Keith - Feller
(OPTIONAL - SEE REVERSE) 600-56-9917
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. N Y B Dutchess
(STATE) otI (COUNTY)
C CHECK ONE 0 CITY 0 f?cWN 0 VilLAGE
AND W - II
SPECIFY appmgers a s
D. STREET ADDRESS 4 ~oy Avenue, Apt. 2
14. EMPLOYMENT
A. USUAL OCCUPATION Nursing Assistant
B. TYPE OF INDUSTRY OR BUSINW,s vassar HospItal
15. PLACE OF BIRTH Everett, ashlngton
(CITY, STATE/COUNTRY IF NOT USA)
YEAR
16. FATHER
A NAME Alvin Keith
B. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Vena Wilson
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOOCE CIVIL ANN'(JMENT
DEA~
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DA Y 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 0
o 0
o 0
o 0
d that I declare that no legal impediment exists
by New York Domestic
TIME
MONTH
SIGNATURE ~
MAILING ADDRESS
20 Middlebu
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
DATE 03/18/200
aPDinQer Falls, NY 12590
dfvnowN STATE ZIP
26 SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO DAY YEAR 0 0 RELIGIOUS
/3" !l!Ill!
PM
TITLE {MffJG.rc L,J ~1'1CL.1t21 j
DATE 1J//f4 I( ~
tU,,1pliw~ Ft9p..s,. NY- /.:).:5 a
STATE
CJ2..
9 0 OTHER, SPECIFY
29 OFFICIANT
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
AM
02 ARM
03
1,K( CIVIL
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY lJ//-rCffc$'';
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF C VILLAGE OF
SPECIFY PouG-Hl<EF-.Ps i E-
.
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) IE /2 I
1\
SIGNATURE ~