124
0-
N
+
,.. ~
z :>
W
(/) or(
W
<Xl C
0 it
-'
::l
0 LL
I
(/) or(
Z
0
~
a:
l-
(/)
a
W
a:
W
(!l
..
a:
a:
..
:>
u.
0
W
~
0
u:
F
a:
W
0
W
a:
W
I
;:
m
m z
W
a: 0
0 z
0 ..
.. ,..
>- w
w
u. a:
li I-
W rn
0-
m
W
en
z
w
0
:i
+
~:i:i W
::l!::Q
Iii;: I- ~
a:~;:j
ti~~ 0
::lOW
:>(!l5 it
I-zm i=
z-
n~~ II:
ttam w
01->- 0
Lii~~
...ffilt)
~~~
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~: 1368 .
~~~I~~~R 124
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Y::mn~~~f~~~~' nC;?J~~~/~~tME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Eliz~~~J~ Cathlee~u~~VYuRNAME
~
11. A. FULL NAME
FIRST
1 . A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY
$ATE)
C. CHECK ONE 0 CITY '&
AND W .
SPECIFY ~rpmger
D. STREET ADDRESS 11 White Gate Dr: Apt E
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 079-66-2659
12 RESIDENCE A. NY B, Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY [J" TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREET ADDRESS 11 White Gate Dr: Apt E ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r::1 NO
O~ /?6 /1981
MONTH DAY YEAR
B. Dllt~hp.~~
(COUNTY)
TOWN 0 VILLAGE
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MON9H4 / D?vO / YE1~81
13. A. AGE ?8
13B.DATE OF BIRTH
3. A. AGE 29
3B. DATE OF BiRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Retail
B. TYPE OF INDUSTRY OR BUSINESS Furniture Retail
15. PLACE OF BIRTH Pouahkeepsie. New York
.. (CITY, STl'TE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Arthur Kelly
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Susan Carol Albert
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATION Stn~k Rrnkp.r
B. TYPE OF INDUSTRY OR BUSINESS Finance
5. PLACE OF BIRTH Montnellier, France
(CITY , STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME M~r~p.1 r.hri~ti~n Fr~n~oi!=: Dnll~h::mt
B. COUNTRY OF BIRTH France
7. MOTHER
A. MAIDEN NAME Gisele Hllguette Fonters
B. COUNTRY OF BIRTH France
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
gal impediment exists
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, thatt
as to my right to enter into the marnage ate.
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
LoLl!lx_kn~wledge and belief that the information I provided is tr e
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 CITYJCLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
TIME MONTH YEAR
SEAL SIGNATURE.
'--- -.J MAIL~~'N1't 08:321.M 09
-v-- PM
by New York Domestic
MONTH
YEAR
11
06 2010
08
2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~U#~~5.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 15 TOWN OF 0 VILLAGE OF
SPECIFY~ \ 1 jP ('"
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1~IVIL
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE.
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ~L:
SIGNATURE.
n()~_aR. Ina/?nna)