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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
loeafarley Ki~AR!~( SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~; 1368 .
~E~I~~~R 115
1. A. FUll NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 1 :\:\-7n-??n~
2. RESIDENCE A. N;trATE) B. gMt~e.,s
c. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ~rrlnop.r
D STREET ADDRESS 6 Cameron Lane
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES r!f NO
MO~.f / 01,2 / yl~87
3. A. AGE 23
3B. DATE OF BIRTH
to-
- :;
<C
C
u:
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<C
4. EMPLOYMENT
A. USUAL OCCUPATION Armed GII~rd
B. TYPE OF INDUSTRY OR BUSINESS Secllrity
5. PLACE OF BIRTH Pnllnhkeen~iei NY
(CITY, Si'j(TE / COUNTRY IF NOT USA)
6. FATHER
A NAME lohn Farley Kirg III
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A MAIDEN NAME .Jlllie Anne Gnewllch
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. 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) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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 STA TE USE ONL Yi
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Nicnlp;'ufotyse Kotsi~~R~E~~i~~JRNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I<i no
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 084-74-7267
12. RESIDENCE A. NY B. nlltches~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 3 Walnut Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
Of) /11 /1 ~RR
MONTH DAY YEAR
13. A. AGE ??
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Phlehotomist
B. TYPE OF INDUSTJ:l~()R BUSINESS Medical
15. PLACE OF BIRTH Bronxville. NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Roy Kotsinadelis
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Patricia Ann Lillo
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 (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /.
MONTH DAY YEAR
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
o 0
o 0
o 0
o 0
o legal impediment exists
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the m
21 SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
that to the best of my knowledge and belief that the information 1 provi
a
23. SUBSCRIBED AND SWORN TO FFIRMED BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork 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 n C. Mas
~
{ SEAL }
'-v-'
DATE
08/31/2010
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
SIGNATURE ~
MAILING ADDRESS
20 Middle
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 08/31/201
ush Rd. WappinQers Falls. NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 ~ELlGIOUS
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
11 :29\M
PM
09
01
2010
10
30 2010
10 CIVIL
2B. PLACE WHERE MARRIAGE OCC~RED
A. STATE NEW YORK B. COtN'{;.[ 'f otf sf;; fi
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY OFD TOW~ OF 0 VILLAGEjF
SPECIFY J1rr l) f; t. AJ ,1 _
NAME (PRINT)
SIGNATURE~