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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.Inn r. Nplli!':
MIDDLE CURRENT SURNAME
0"'" 0 1 ST 0 0
0"'" 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
ledge and belief that the information 1 provided is true and that I declare that no legal impediment exists
22 SIGNATURE OF BRIDE ~ h-&WfLfrie- fl{;j;l1tP_ e--
I USE CURRENT~E ~
DATE 11/16/2001
by New York Domestic
COUNTY ntJtche~~
CITYITOw"N Wappinger
. ~~~~kCRT 1 ~RR
~~~'~J~R 1 ~ 1
A FULL NAME
FIRST
0-
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
,OPTIONAL. SEE REVERSE) 0"'5-10-? "2 j
o SOCIAL SECURITY NUMBER _0_ -- -~--
2 RESIDENCE A. N Y B
. (STATE)
C CHECK ONE 0 CITY 0 TOWN [Y'VILLAGE
AND
SPECIFY Wrlppinger~ F;:)II~
o STREET ADDRESS 30 South Avenue
gJdt~p!,:!,:
ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? DlYES 0 NO
3 A AGE 31 3B DATE OF BIRTH MONQ3 / DR6 / YE'Jr,.97
4 EMPLOYMENT
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A USUAL OCCUPATION $pr.llrity ~rpr.i;:)li!':t
B TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTH Pnll(1hkeen~ip,,-- N Y
(CITY. S~TEiCOUNffiy IF NUT USA)
6 FATHER
A. NAME Robert AIIE>n Nellis
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A MAIDEN NAME Dorothy Elizabeth Keough
B COUNTRY OF BIRTH I I S A
B NUMBER OF THIS MARRIAGE ~
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
[}
?
o
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT
C DATE LASt MARRIAGE ENDED? 00/ 01 /
MONTH DAY
o ARE ANY FORMER SPOUSE(S) ALIVE? O~ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY. STATElCOUNTRY. IF NOT USA) SELF SPOUSE
(2) 0 DEATH
2000
YEAR
02/24/1998 POlIgh~psie, NY
n~1011?()()() Pnllohkeep!':ie. N Y
I
SlAIt: tiLt:. ....UMCr:.M
(THIS SPACE FOR STA TE USE ONL Y)
[r,
/I '.I " ,
'rJ>, /
Ihf1-ti /
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~tpphrlnie Pevrnnnette
MIDDLE J CURRENT SURNAME
~
11. A FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Nellis
(OPTIONAL' SEE REVERSE)
o SOCIAL SECURITY NUMBER oq~-9n-79~n
12 RESIDENCE A. N1stTE) B r;l~!~qe!':!=;
C CHECK ONE 0 CITY O",,"OWN 0 VILLAGE
AND W h' t
SPECIFY r1~ Ing on
D. STREET ADDRESS 278 Chestnut Ridge Road ZIP 12545
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES oINO
13.A.AGE 27 13.B.DATEOFBIRTH fY) /~Cl /~yQAi74
MOmFr OAT rAIl
14. EMPLOYMENT
A. USUAL OCCUPATION ~I lCient
B TYPE OF INDUSTRY OR BUSINESS Mari~t College
15. PLACE OF BIRTH Rnrrlerlll'J( Franr.e
(CITY. STATEiCOUtlTRY IF NOT USA)
16. FATHER
A NAME AI<3in Ppyrnnnpttp
B COUNTRY OF BIRTH Frrlnr.e
17. MOTHER
A. MAIDEN NAME Christine Riviere
B. COUNTRY OF BIRTH Fr::lnce
1B NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
[} 0
DEATH
o
(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
23 SUBSCRIBED AND SWORN FORE M
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 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 CLERK 25 A SOLEMNIZATION PERIOD BEGINS
21. SIGNATURE OF GROOM
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{ SEAL }
"-y-I
TIME
MONTH
YEAR
MONTH
YEAR
11/1 R/?OO
AM
12:35'M
15 2002
11
17
20 1 01
ZIP
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
STATE
27. TYPE OF CEREMONY
o ji.. RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
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";"Sf'l."'S:, ., riltt". /Jf1.rl'/"'~cA f-pm N J /
STREET ~ITY/TOWN ,., STATe'
30 WITNESS TO C
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B COUNTyJ),-/ -IcL e ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY l Jr)ff':rJif"V?J ti.ik
31.
NAME (PRINT)
SIGNATURE ~
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