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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST LllkbiD~plMard M9!LlQ~SURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c~ 1 368 .
~~~':J~R 11 9
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ancirp.;:! I P.P. Alhll~
MIDDLE CURRENT SURNAME
-.J
11. A. FUll NAME
FIRST
..
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE M(;lnop.l~
(OPTIONAL - SEE REVERSE) 068 66 4867
D. SOCIAL SECURITY NUMBER ___- __ -____
12. RESIDENCE A. NY B. nl Jtr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY Ii2'I TOWN 0 VILLAGE
~~~CIFY Beekman
D. STREET ADDRESS 6603 Chelsea Cove Drive
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 ?-7 4-n~!i!i
2. RESIDENCE A. NXTATE) B. E?c~!tf~E'SS
C. CHECK ONE 0 CITY It'I TOWN 0 VILLAGE
AND
SPECIFY RAp.km;:!n
D. STREET ADDRESS 6603 Chelsea Cove Drive ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 28 3B. DATE OF BIRTH MOJJ. / 017 / Yt~80
4. EMPLOYMENT
A. USUAL OCCUPATION I II :tt~p, ~hep.tmp.t~1
B. TYPE OF INDUSTRY OR BUSINESS C:nn~trLJr.tinn
5. PLACE OF BIRTH NAW Rnr.hAIIA NY
(CITY, STATE / COUNTRY IF'NOT USA)
6. FATHER
A. NAME Rnhl"rt I (;llMrp.nr.1" M~nop.l~
B. COUNTRY OF BIRTH l J S A
7. MOTHER
A. MAIDEN NAME K;:JthlAAn Franr.A~ MagliLJlo
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 n
DEATH
o
ZIP 12533
o YES~ NO
/l'QR?
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 27 3B. DATE OF BIRTH ()1 ,,-?Q
MONTH DAY
t-
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14. EMPLOYMENT
A. USUAL OCCUPATION Admin A~sistant
B. TYPE OF INDUSTRY OR BUSINESS Aviation
15. PLACE OF BIRTH Bronx, NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Thnm;:J!'; ,1;:Jme~ Albu~
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Beverly Gail Schneider
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
n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEAJH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END?
YEAR
C. DATE LAST MARRIAGE ENDED?
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
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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
edge and belief that the information I provided is true and
o 0
o 0
o 0
o 0
iment exists
21. SIGNATURE OF GROO
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEF RE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New. York State of the bride and groom named abo any person au
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
w
en
z ~
W
~ {SEAL}
"-v-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DATE 1 0/07/200
ers Falls NY 12590
N STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS
i 0 0 C( ;).c{A 9 0 OTHER, SPECIFY
AM
02:26PM
2009
12
06 2009
10
08
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRED
l~IL
A. STATE NEW YORK B. COUNTY
bu rates S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 6WN OF 0 VILLAGE OF
29. OFFICIANT
NAME (PRINT)
TITLE
N/~(AG-e ~/ct~
i of Clc } 0 1
1.:oJ ,)ct 0
ZIP
31. WITNESS TO CEREMONY
^ Ii IC.L\ AI)
NAME (PRINT) I::n . "-
tAl ft pP 1,J6E(L
DATE
SPECIFY
1\)'
STATE
SIGNATURE~
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