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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c: 1368 .
~5~~~~R 138
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kei'ucf dw~ rrl Rcfu~RV~ SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Katharine Elizabeth Oakhill
MIDDLE CURRENT SURNAME
-.J
1 . A FULL NAME
11. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 047-78-2600
2. RESIDENCE A. CT B. F~irfiAlrI
~TATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND
SPECIFY ShArm::ln
o STREET ADDRESS 11 Church Rd ZIP 06784
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!'1 NO
3. A. AGE 24 3B. DATE OF BiRTH MO~~ / Df,9 / yJA~86
4. EMPLOYMENT
A. USUAL OCCUPATION RllrnAr T Ar.h
B. TYPE OF INDUSTRY OR BUSINESS Boilers
5. PLACE OF BIRTH New Milford. CT
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Michael P(:'lIll Re~tty
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME K::IthlAen Anne Conroy
B. COUNTRY OF BIRTH LJ S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE RA::Itty
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 097-78-8651
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!l' TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
o STREET ADDRESS 39 Victor Lane ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
13. A. AGE ?? 13B.DATE OF BIRTH 08 /?6 /i 988
MONTH DAY YEAR
w
S
'"
14. EMPLOYMENT
A. USUAL OCCUPATION Deli Clerk
B. TYPE OF INDUSTRY OR BUSINESS IGA
15. PLACE OF BIRTH North Tarrytown. NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Harold Westlake Oakhill
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Emily Jane Dahlberg
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that
as to my right to enter into the m
21. SIGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN TO/AFF
SIGNATURE OF TOWN OR CITY
DATE 1 0/05/2010
by New York Domestic
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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo C. Mas
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 10/05/201
MAILING ADDR,Eil' AM
'-v-I 20 MioOleb in ers Falls NY 12590 03: 13>M 10
STREET CITYITOWN STATE ZIP
~~~~~~RT:~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o)q- RELIGIOUS
DATE AND AT THE TIME AND I AM
W PLACE INDICATED. 'r} p I 0 'I l ';ltJ /0 9 0 OTHER, SPECIFY
~ ~~J>:~~~~~T I< E iT h W '--;;C;f"I L y N TITLE ~e /.J~ru. ~L
~ SIGNATURE ~ J (;{;tf, {~~J" DATE / lJ //1'/:;2-0/ ()
i= MAILING ADDRESS """7 '/ ~ , J I J / 9 ,,"}
a: Is-to ~c;.ly~- s 6 Iv&{ _~~ 0'4 f~f.J 1'1. l.( , /;).5" {j
W STREET
() 30. WITNESS TO CEREMONY
W
(J)
Z
W
()
::::i
MONTH
YEAR
06
2010
12
04 2010
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY "7)u Tc hess
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~TOWN OF 0 VILLAGE OF
SPECIFY W Al2.JJJnq (.r
'/ V
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
ZIP
31. WITNESS TO CfREMONY t:::'"
NAME (PRINT) --f.-..-....... (0/ r :
SIGNATURE~ ~- ?
STATE