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ST A TEOF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason T. Conway
FIRST MIDDLE
Dutchess
COUNTY
~ITOWN . Wappinger
DISTRICT 1368
NUMBER
~5~~J~R 118
1. A. FUll NAME
CURRENT SURNAME
3 BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 030-66-4494
D SOCIAL SECURITY NUMBER
2. RESIDENCEA Massachusetts
(STATE)
C CHECK ONE 0 CITY ~ TOWN D
~~~CIFY Hull
D. STREET ADDRESS 50 B Street
B Suffolk
(COUNTY)
VILLAGE
ZIP 02045
_ IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
/ 28 /1972
DAY YEAR
3. A. AGE
27
3B. DATE OF BIRTH Dec.
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Product Designer
B TYPE OF INDUSTRY OR BUSINESS Se If Emu loved
5 PLACE OF BIRTH Wevmouth. Mass.
(CITY, STA'l'EiCOUNTRY IF NOT USA)
6. FATHER
A. NAME Arthur T. Conway
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Karen M. Sutherland
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
B. HOW DID LAST MARRIAGE END? (31 = DIVORCE ',31 = ANNULMENT (2) C DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? = YES = NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
,MONTH. DAY, YEAR) 'CITY, STATE COUNTRY. IF NOT USA! SELF SPOUSE
1ST
2ND
3RD
4TH
I. being duly sworn, depose and sayl that to th
as to my right to enter into the marriage state,
21 SIGNATURE OF GROOM ~
-"
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I :11"11: rll..c; nv_u~n
(THIS SPACE FOR STA TE USE ONLY)
/~~(U
L =:J SUPPLEMENTAL FILE .J
11 A. FUll NAME
FROM THE BRIDE
Jana L. Karr
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME ,MAIDEN NAME). IF DIFFERENT
C, SURNAME AFTER MARRIAGE COnWay
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 093-68-4885
12. RESIDENCEA New York B. Dutchess
,STATE) ,COUNTY'
C. CHECK ONE ~ CITY D TOWN C VILLAGE
~~~CIFY Beacon
D. STREET ADDRESS 27 Van Ness Rd. zIP12508
E, IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VilLAGE? ~ YES D NO
13.A AGE 23 13.B,DATEOFBIRTH Sent. /20 /1.976
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Greenwich B0ard Ed.
15, PLACE OF BIRTH Newburl!:h. New York
(CITY, STATEiCOUm'RY IF NOT USA)
16, FATHER
A. NAME William E. Karr
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME
To-M~rip r.~rhon~ro
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE Firs t
19. PREVIOUS MARRIAGES
A. NUMBE::; OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
2: = DEATH
B. HOW DID _~ST MARRIAGE END? (3) C DIVORCE 3\ = ANNUL.\'E'. T
C. DATE ..AST MARRIAGE ENDED? /
MONTH :;A y VE.o\R
D ARE ~NY =ORMER SPOUSE(S) ALIVE? = YES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOlLCWING INFORMATION
DATE 8F DECREE PLACE ISSUED AGAINST WHOM
(MONTH JAY. VEARI !.CITY STATE/COUNTRY, IF NOT USA' SELF SPOUSE
1ST
2ND
3RD
" 4TH
"owledg; and belief that the information I prOVided is true and that I d
^-----
k USE URREN NAME
DATEJuly 24. 2000
This license authorizes the marriage in New York Sta of the bride and groom named above by any person authorized by New York Domestic
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 ER~laine H. Snowden, Town Clerk 25. A. SOLEMNIZATION PERIOD BEGINS
23.
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{ SEAL }
'-.,-I
NAME (PRINT)
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)
TITLE
DATE
SIGNATURE ~
DOH-98 (1198)
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
DATE 7/24/00
NY 12590
7
25
00
09
22
00
AM
2 : 15>M
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWfi OF ~GE OF
SPECIFY ~v~/#<ge25 !'/ltJ;>
1 = CIVIL
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( 2.5]0
ATE
SIGNATURE ~