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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~P:::m ~jQh::lAI WitkJa~M~uRNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND. 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swe!lr/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my nght to enter Into the marnage state. JJ
Y' ~....._ .--c..,.. ~ ~ 1/
21. SIGNATURE OF GROOM~ ~/7 22. SIGNATURE OF BRIDE~ J)~~"" ff-f ^/U.
USE C USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 05/03/2010
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New Y k State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to periorm 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
NAME (PRINT)
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~ 1368 .
~G~:~~R 43
1. A. FUll. NAME
FIRST
Q.
I'l
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSEl...47 76 5362
D. SOCIAL SECURITY NUMBER 1L_ - --- ----
2, RESIDENCE A. NY B, nllt~hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY.,(J TOWN 0 VILLAGE
AND P hk .
SPECIFY Ollg eepsle
0, STREET ADDRESS 18 Donny Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES""O NO
3. A, AGE 26 3B, DATE OF BIRTH 11 / ?7 /1983
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION In~t::lll M::ln::lger
B. TYPE OF INDUSTRY OR BUSINESS Fire Alarm
5. PLACEOFBIRTHWorce~ter, MA
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A, NAME [v1i~h::lAI .I::lmp~ Witkow~ki
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Flizabeth Helen Bauld
B. COUNTRY OF BIRTH Scotland
8. NUMBER OF THIS MARF,UAGE 1
9. ~~~~~~iRMtf~~A~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
a:.'
W
m
::!
~
Q
~
Iii
W
~
~
{ SEAL }
~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29, OFFICIANT
NAME (PRINT)
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
Lo
-.J
SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica Lee Herrell
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B, BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C, SURNAME AFTER MARRIAGEWitkowski
(OPTIONAL. SEE REVERSe. 27 -72-4409
0, SOCIAL SECURITY NUMBER 'I
12, RESIDENCE ANY BPutnam
(STATE) (COUNTY)
C, CHECK ONE 0 CITYootJ TOWN 0 VILLAGE
~~~CI~atterson
D. STREET ADDRESS1 035 Route 311
ZIp12563
o YES.....O NO
.1'983
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGF27 3B. DATE OF BIRTH 04 JOT
MONTH DAY
14. EMPLOYMENT
A, USUAL OCCUPATIONRecreation Leader
B. TYPE OF INDUSTRY OR BUSINESsNursing
15. PLACE OF BIRTHCarmel, NY
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEWilliam Keith Herrell
. B. COUNTRY OF BIRTM S A
17. MOTHER
A. MAIDEN NAME Eileen McGourty
B. COUNTRY OF BIRTM 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
(3) 0 ANNULMENT (2) 0 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. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
TIME
MONTH
YEAR
MONTH
YEAR
AM
01:15PM 05
02 2010
04
2010
07
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYJ) v'7C;~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY f'l7w t.;: IV fr
R.~. P~~ST
.r /;"1 /J 0
Y' '/-tiC{
ZIP
31. WITNESS TO C EMONY
NAME (PRINT)
SIGNATURE~
t1