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COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT1365 .
NUMBER
REGISTER42
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Conrad Phillip Tebbetts, Jr
MIDDLE CURRENT SURNAME
r
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jolynne Tullis
MIDDLE
CURRENT SURNAME
1, A. FULL NAME
11, A. FULL NAME
FIRST
FIRST
..
IQ
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE053_68_5670
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE).L. (COUNlY)
C. CHECK ON,,- 0 CITY'U. TOWN 0 VILLAGE
~~~CIFY t-'oughkeepsle
D. STREET ADDRESS 21 I ownsena I:Slva. ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? f
3. A. AGE 27 3B. DATE OF BiRTH 05 / 1
MONTH DAY
-12603
>I
Y/f98~
YEAR
B. BIRTH NAME (MAIDEN NAME)f D'S'~elts
C. SURNAME AFTER MARRIAGE e
(OPTIONAL - SEE REVERSE~ 22-60-5520
D. SOCIAL SliGlJfVTY NUMBER
NY uutcness
12. RESIDENCE A. B.
(STATE) It/!. (COUNTY)
C. CHECK ~ H[J CITY [;] TOWN 0 VILLAGE
AND t-'oug IKeepSle
SPECIFY 21 Townsend elvd. 12603
D. STREET ADDRESS ZIP
.,
E. IS RE~~NCE WITHIN LIMITS OF CITY OR INCORPORA1f~ VILLAGE?1dI. 0 Y~JJ,10
13. A. AGE 3B. DATE OF BIRTH C E
MONTH DAY YEAR
14. EMPLOYMENT D' C t t'
eSlgn ons ruc Ion
A. USUAL OCCUPATION New YorK State ParKs
B. TYPE OF IND~mn%~~~~ESN
15. PLACE OF BIRTH ' Y
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER Ed d J T II'
war ames u IS
A. NAME USA
B. COUNTRY OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUATRY OR BV~INESS Retail
5. PLACE OF BIRTH I:Sronx, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Conrad Phillip Tebbetts Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER .
A. MAIDEN NAME Dawn Mane Herbst
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARF,UAGE
9. ~~~~~~~R~FR~~AE<vr8us MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL A~ULMENT
17. MOTHER
Jolene Ann Iacobucci
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DeyORCE CIVIL Atl"ULMENT
D'CtTH
D"d TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
..- YEAR
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) (CITYICOUNlY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
to
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNlY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, aep'ose and say, th
as to my right to enter into the marn
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
wledge and belief that the information
USE CUR
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 c,LERK.-" M t 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) JOnn \j. as erson
{SEAL} SIGNATURE ~
MA~!f~~~bu
'-v-I
by New York Domestic
DATE 05/03/2010
Rd, Wappingers Falls, NY 12590
TIME
MONTH
02 2010
YEAR
MONTH
YEAR
2010
07
AM 05
12:46 PM
04
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 0 RELIGIOUS
9~HER, SPECI
ZIP
28. PLACE WHERE MARRIAGE OCC~ . .
A. STATE NEW YORK B. COUNTY ~.!2.4:
-
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
r,:,t"l;:)~ OF ~N OF
SI AT
MAl
t
STREET
~w~~. E MONY
NAME (PRI~
SIGNATUR
, )JcJ.kvt-e-
-