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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thnm~~Doferlw~rrl Kfb~~~t ~R'iME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~: 1368
~~~~~~R 131
1. A. FUll NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 123-70-1365
D. SOCIAL SECURITY NUMBER _ __ __ _ ___
2. RESIDENCE A. NY B. III~tAr
(STATE) (COUNTY)
C. CHECK ONE I!itl' CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Kingston
D. STREET ADDRESS 41 Clarendon Ave ZIP 12401
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~ YES 0 NO
3. A. AGE 39 3B. DATE OF BIRTH 10 / ?8 / 1 Q70
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION nrAr~ting FnginAAr
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Kinaston, New York
(CITY, ~ATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME RohAn Thnm::l~ KA~nA
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Colleen Mary Murray
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
g. 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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
MONTH DAY
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Brianne Lynn Tibbetts
MIDDLE CURRENT SURNAME
~
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kp.~np.
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 101-66-6374
12. RESIDENCE A. NY B. Ulster
(STATE] (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND K' t
SPECIFY Ings on
D. STREET ADDRESS 41 Clarendon Ave ZIP 12401
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? r:'1 YES 0 NO
13. A. AGE 31 13B.DATE OF BIRTH 02 /12 /1979
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Receptionist
B. TYPE OF INDUSTRY OR BUSINESS Doctors Office
15. PLACE OF BIRTH Yonkers, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Ronald Ernest Tibbetts
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Diane Mary Kenneally
B. COUNTRY OF BIRTH USA
1 B. 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 (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /.
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
(2) 0 DEATH
YEAR
,.
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
o
o
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the mama
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
to the best of my knowledge and belief that the information I provided is tr
tate.
USEC
23. SUBSCRIBED AND SWORN TOIA IRMED BEFORE ME
SIGNATURE OF TOWN OR CITY LERK ~
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) John C. Mas erson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 09/24/201
"- -.J MAILWlll\PP.IR~~~e AM
-v- ~u Miami sh Rd, WappinQers Falls, NY 12590 03:15:>M 09
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNiZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- ~
SONS NAMED ABOVE ON THE TIME MO, DAY YEAR 0 c3" RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. / () 9 0 OTHER, SPECIFY
W
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TITLE
DATE
12",/6-
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
DATE 09/24/2010
by New York Domestic
MONTH
YEAR
25
23 2010
2010
11
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY J Idp}-
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY t; li.I~~1o "-.J
STATE
NAME (PRINT)
SIGNATURE~