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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Rrya~IDliEmothy HOJfl!~NT SURNAME
couNrDutchess
CITYfTow"wappinger
~~~:~cR~ 368 '
~5~I:J~'22
1 , A. FUll NAME
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE;j.
o SOCIAL SECURITY NUMBER :J50-77 -3060
2, RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D Towlt'D VilLAGE
~~~CIFY Fishkill
0, STREETADDRESs102-E Weston Ave ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~ YES D NO
04 /23 /1983
MONTH DAY YEAR
3. A. AGF26
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION T p.acher
B. TYPE OF INDUSTRY OR BUSINESsEducation
5, PLACE OF BIRT..Lona Beach Ca
(CITY;1lTATE I COUNTRY IF NOT USA)
6, FATHER .
A. NAME M:::Irk r.hristnpher Hogan
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Yolanda E Moran
B. COUNTRY OF BIRTH Cuba
8. NUMBER OF THIS MARF,lIAGE 1
9. ~~~~~~~R~f~~"E<tT8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEAJI1
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
D D
o D
o D
,-I'-..
{ SEAL }
'-v-I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SIGNATURE~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
Lo
..J
SUPPLEMENTAL FILE
FROM THE BRIDE
Kelliann Davis
11. A. FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGlHogan
(OPTIONAL' SEE REVERS'09-68-3554
D. SOCIAL SECURITY NUMBER
12. RESIDENCE NY put chess
(STATE) J (COUNTY)
C. CHECK ONE P CITY 0 TOWJ<:I 0 VILLAGE
~~cIJ:ishkil
STREETADDREJ02-E:. weston Ave
14. EMPLOYMENT
A. USUAL OCCUPATlotl\dvertising Sales
B. TYPE OF INDUSTRY OR BUSINES~n!ertamment
15. PLACE OF BIRT"p'oughkeepsle, Ny
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMeJames Edward Davis
'B. COUNTRY OF BIRTJyJ S A
17. MOTHER .
A. MAIDEN NAMEKathleen Lillian Welt
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DaORCE CIVIL A8NULMENT
D(tTH
(3) 0 ANNULMENT (2) D DEATH
/ /
. - YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o D
o D
o D
o D
egel impediment exists
DATE
by New York Domestic
TIME
MONTH
YEAR MONTH
YEAR
03:23~~ 03
31 2010 05 29 2010
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTY.~~S
R. C. -jJ,e Ifs,
. t:) /7 f/'o
,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF pA!CLAGE OF
SPECIFY VtJ~/I\)G-("KS rltu'~
I ;)..!;9o
ZIP
31. WITNESS TOf7RE,:,!ONY --;-U /J ~ d
NAME (PRINT) /CtJ I (). f^.- Y1 /
SIGNATURE~ t_a-({~ ^. ~