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L D SUPPLEMENTAL FILE
FROM THE BRIDE
Eileen Nicole Kent
MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)87 -78-7926
D. SOCIAL SECURITY NUMBER
12. RESIDENCE NY putchess
(STATE) u J (COUNTY)
C. CHECK ONE 0 CITY" 0 TOWN 0 VILLAGE
AND \AI .
SPECI"".!. applnger
D. STREET ADDRESi03 Popula Blvd
COUNTYDutchess
CITY/TOwNWappinger
~~~~f~1368 .
~5~1:~~~5
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
nArlpU;D~~Y Rardn~~RR~J SURNAME
I
1. A. FULL NAME
11. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERS~
D SOCIAL SECURITY NUMBER tl57 -83-2084
2. RESIDENCE A.NY B. Dlltchess
(STATE) (COUNTY)
C. CHECK ONE 0 ClrMJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDREss403 Popula Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEYD NO
3. A. AG~27 3B. DATE OF BIRTH 11 /24 /1982
MONTH DAY YEAR
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
"I
-.l
FIRST
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~5 3B. DATE OF BIRTH 08 p.2
MONTH DAY
ZI~ Lb9U
01
o YES 0 NO
:J,@84
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION ()pAr::ltion Manager
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH~an Dieao, Ca
(CITY, STATE ft:OUNTRY IF NOT USA)
6. FATHER
A. NAME DE'rlpr R::lY R::lrdnpy
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Myra Ambrose
B. COUNTRY OF BIRTH L J S A
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
14. EMPLOYMENT
A. USUAL OCCUPATloJransfer Counselor
B. TYPE OF INDUSTRY OR BUSINESFducatJon
15. PLACE OF BIRTtP.Ort Jervis, Ny
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAM~homas Raymond Kent, Jr.
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAMJ.:eann Smith
B. COUNTRY OF BIRT",", S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DOATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. -.~ YEAR
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 ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
USE CURRE
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge a d belief that the information I provided is true a
as to my right to enter Into the mama estate.
21. SIGNATURE OF GROOM ~ 2. SIGNATURE OF BRIDE ~
r-I'-.
{ SEAL }
~
NAME (PRINT)
DATE 04/22/2010 TIME
ers Falls NY 12590 10:04 AM
WN STATE ZIP PM
27. TYPE OF CEREMONY
o.Rl RELIGIOUS
20 10 9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
t(
TITLE 1/15'7 n,R
DATE '/- ,30 - 201 D
MY. 12"77
STATE
NAME (PRINT)
SIGNATURE~
o
o
o
DATE 04/22/2010
by New York Domestic
MONTH
YEAR
MONTH
YEAR
04
23
2010
06
21 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY /)tS7['HifS11fL
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
g CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY IV.i'tJ ;ft}{'lIeub
~~