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COUNTY Dutchess
CITYfTOWN Wappinger
~~~=~c: 1368 .
~~~~l~R 7 0
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin Joseph Gennodie
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Evelvn Marie Martin
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFEREN~esselberg
C. SURNAME AFTER MARRIAGEGennodie
(OPTIONAL - SEE REVERSE1 06-62-5581
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYootJ TOWN 0 VILLAGE
~~~CIFYPoughkeepsie
D. STREET ADDRESp6 Cardinal Dr
-.J
1. A. FULL NAME
11. A. FULLNAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb99 70 7227
D. SOCIAL SECURITY NUMBER --- - -
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
AND P hk .
SPECIFY Dug eepsle
D. STREET ADDRESS 56 Cardinal Dr ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEs"tJ NO
05 /01 /1970
MONTH DAY Y~R
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE36 3B. DATE OF BIRTH 06 ,26
ZIp12601
o YES ""0 ND
)'973
Y~R
3. A. AGE4n
3B. DATE OF BIRTH
MONTH
DAY
14. EMPLOYMENT
A. USUAL OCCUPATIONKitchen Designer
B. TYPE OF INDUSTRY OR BUSINESsRetail
15. PLACE OF BIRTHCortlandt, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMERobert Harold Sesselberg Jr
'B. COUNTRY OF BIRTt-W S A
17. MOTHER
A. MAIDEN NAME Mary Agnes McGrath
B. COUNTRY OF BIRTt-W S A
18. NUMBER OF THIS MARRIAGE 2
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Hardware
5. PLACE OF BIRTH Mount Kisco. Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Victor Louis Gennodie
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Elaine Madeline Leaner
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARI'lIAGE 2
a:
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ID
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9 PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
. A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
1 0 0 1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (g) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 27 / 2007 c. DATE LAST MARRIAGE ENDED? 06 / 22 / 20u7
MONTH DAY Y~R MONTtlt DAY'- Y~R
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
09/27/2007 Poughkeepsie. Nv 0 ~ 1ST 06/22/2007 Westchester, Ny 6 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
t of my knowledge and belief that the information I provided is tr n~ that I declare that no legal impediment exists
DEATH
USE CU
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 onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
by New York Domestic
w
tJ)
Z rJ-.
~ { } NAME (PRINT)
:::::i SEAL SIGNATURE ~
MAILlNG.A9D S
'-.,-I 20 Mi (j
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
MONTH
YEAR
TIME
MONTH
08:42AM 06
PM
26
2010
08
24 2010
1~.
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TLE -:r~(),t..
Jf.
NAME (PRINT)
SIGNATURE~