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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368
~~~'~J~R 11 7
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Fr;:Jnci~co Moises C;:Jmev
MIDDLE CURRENT SiJllNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kim~~~!r Marie OPu~~~~SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 099 72 4578
D. SOCIAL SECURITY NUMBER ___ - __ - ____
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY!i!'f TOWN 0 VilLAGE
AND W .
SPECIFY applnger
o STREET ADDRESS 5 Wildwood Dr: Apt 10a ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 24 3B. DATE OF BIRTH 1? / 17 / 1 9RS
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Carney
(OPTIONAL - SEE REVERSE) 118 72 2714
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
~~~CIFY Waooinger
D. STREET ADDRESS 5 Wildwood Dr; Apt 10a ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
12 /28 /'1983
MONTH DAY YEAR
13. A. AGE 26
14. EMPLOYMENT
A. USUAL OCCUPATION Financial Advisor
B. TYPE OF INDUSTRY OR BUSINESS Financial Institution
15. PLACE OF BIRTH Pouahkeeosie. New York
(CITY, STATE f COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Frank Oberst Jr.
'B. COUNTRY OF BIRTH USA
13B.DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Chef
B. TYPE OF INDUSTRY OR BUSINESS Hospitality
5 PLACE OF BIRTH Cortlandt. New York
(CITY, STATE f COUNTRY IF NOT USA)
6. FATHER
A. NAME George A C;:Jmey
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patricia X. Ubilla
B. COUNTRY OF BIRTH Chile
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
17. MOTHER
A. MAIDEN NAME Susan Kim Morrison
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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) (CITYfCOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say,
as to my right to enter into the marr
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is true and that I
o 0
o 0
o 0
o 0
legal impediment exists
DATE 09/01/201 0
by New York Domestic
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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.
,-I"-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 09/01/201
\..- -J MAIL.ltl~ J\D~IRF&~e 09 22AM
-v- LU Mlaall sh Rd, Wappingers Falls, NY 12590 : 09
STREET CITYITOWN STATE ZIP PM
~~~R~~~RT~~~ lo~O~~~N~Zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 Jl RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. PM I G. q . J (!) 9 0 OTHER, SPECIFY
29. OFFICIANT A:JE) ~ c:./JT"" COWTl
NAME (PRINT) fl ~1-'1'- oJ .
SIGNATURE ~ Q,..Q \l .\:l. ~
MAILING ADDRESS ~o-
,~ f)~6L,..,.,e tlSA-c.oJ"l'
STREET CITYfTOWN
30. WITNESS TO
10
31 2010
MONTH
YEAR
02
2010
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY P"TC.\+4$,s
TITLE
PASTblL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY V N J Otv v r'l--L. E.
NAME (PRINT)
SIGNATURE~
DOH-9B (09/2009)
DATE Ocrot3 F..II. q I ,"0 I 0
NY ,~~oe.Jt)oy.
STATE ZIP
31. WITNESS TO C REMONY
NAME (PRINT)
SIGNATURE~