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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher J.
FIRST MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY "Dutchess
XXYrrowr, Wappinger
~5'~~~c~ 13 6 8
~~~~J~R 96
/ '1/1100
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Gerri E.
FIRST MIDDLE
~
Ott
McKeon
11. A, FULL NAME
CURRENT SURNAME
1. A FULL NAME
CURRENT SURNAME
B BIRTH NAME, IF DIFFERENT
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
McKeon
075-68-1815
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
SOCIAL SECURITY NUMBER
2 RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
o CITY ~ TOWN 0 VILLAGE
poughkeepsie
o STREET ADDRESS 405 Cherry Hill
C, SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
o SOCIAL SECURITY NUMBER
12. RESIDENCE A New York
ISTATE)
o CITY ~ TOWN 0 VILLAGE
poughkeepsie
0, STREET ADDRESS 405 Cherry Hill
ZIP 12603
112-70-5764
Dutchess
, COUNTYI
B.
C, CHECK ONE
AND
SPECIFY
C, CHECK ONE
AND
SPECIFY
12603
ZIP
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A, AGE 26 13.B. DATE OF BIRTH March /29
MONTH DAY
YES Xi NO
/1974
YEAR
E, IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE' 0 YES ~ NO
3, A, AGE 27 3B.DATEOFBIRTH Sept. / 22 /1972
MONTH DAY YEAR
14, EMPLOYMENT
4, EMPLOYMENT
A. USUAL OCCUPATION Dental Assistant
B, TYPE OF INDUSTRY OR BUSINESS Dr. Sohn
15, PLACE OF BIRTH Beacon. New York
(CITY. STATEiCOUNTRY IF NOT USA)
A. USUAL OCCUPATION Landscape Contractor
B, TYPE OF INDUSTRY OR BUSINESS Self-Employed
5, PLACE OF BIRTH Bronx, New York
(CITY, STATEiCOUNTRY IF NOT USA)
16. FATHER
A, NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B, COUNTRY OF BIRTH
Mary Wood
USA
First
6. FATHER
A. NAME James McKeon
B. COUNTRY OF BIRTH USA
7, MOTHER
A, MAIDEN NAME Linda Garguilo
B, COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE First
Paul Ott
USA
18. NUMBER OF THIS MARRIAGE
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
9. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B, HOW DID LAST MARRIAGE END' 131 = DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
21 = DEATH
MONTH DAY YEAR
D, ARE ANY FORMER SPOUSE(S) ALIVE' = YES 0 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
B, HOW DID cAST MARRIAGE END' (3) C DIVORCE 31 = ANNUU.\ENT
C, DATE LAST MARRIAGE ENDED? / ,/
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? =:; YES = NO
20, IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE CF JECREE PLACE ISSUEO AGAINST WHOM
',MONTH. DAY. YEAR) ICITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
=:J
1ST
2ND
3RD
'---'
'---'
Town Clerk
DATE June 19 , 2000
by New York Domestic
w
en
z
w
o
::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York ate 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,
::J 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)~Elaine H. Snowden, Town Clerk
{SEAL SIGNATURE~~I"n\.\.sA"\A.,(jvA DATE 6/19/00 TIME MONTH YEAR
MAILING ADDRESS - AM
'-..t-I PO Box 324. Wappingers Falls , NY 12590 1..30 PM 6 20 00
STREET CITYITOWN STATE ZIP
~~~R~~~RT~~~ IO~O~~~N~zEEg 26. SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO, DAY YEAR 0 0 RELIGIOUS 1'l5 CIVIL
DATE AND AT THE TIME AND ') Lie J!lhf a -
PLACE INDICATED '" ~ PM 0 b Qtl 90 OTHER, SPECIFY
~~~tf~9i~~;~'IlCeNT ~.. f'eIklCti9E me' F..._ -;;;,,'" ;Mt". ""'Ii
SIGNATURE~_'W:?l~~ DATE If(/G- s: .20tJo
MAILING ~ S LJ /. ' I U
II f( ~SGt2. 1'0 il2.'4 f(/AfJfJll'/8-E,e..g ?R..t.t.r IV' 7. 1;< S-t::! 0
STREET CITY TOWN
30, WITNESS TO CEREMONY
8
18
00
MONTH
YEAR
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY U1iCl'fs:.ss
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF = VILLAGE OF
SPECIFY ft:> \}Q,if-l(Z:iCPS I..
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) K;e IS r!
NAME (PRINT)
SIGNATURE ~
00H-98 (11198)
SIGNATURE