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COUNTY Dutchess
CITYfTOWN Wappinger
~~J:~c: 1368 .
~5~1:~~R 11 3
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.I~mp.!=; Arr.~ngp.ln Str~ck
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melissa Ashle~ Garcia
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Strack
(OPTIONAL - SEE REVERSE) 1 05 80 7714
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREET ADDRESS 97 Ardmore Dr
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 058-70-2092
2. RESIDENCE A. NY B. DLJtche!=;!=;
(STATE) (COUNTY)
C. CHECK ONE 0 CITY IZ'I TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 97 Ardmore Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE ?4 3B. DATE OF BIRTH 04 / 02 / 1985
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE?
13. A. AGE 22 3B. DATE OF BIRTH 07 /'02
MONTH DAY
ZIP 12590
DYES '6 NO
A987
YEAR
4. EMPLOYMENT
14. EMPLOYMENT
'A.'USUAL oCCUPATION Sales Representative
B. TYPE OF INDUSTRY OR BUSINESS Dick's SportinQ Gooas
15. PLACE OF BIRTH Mt. Kisco, NY
(CllY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Joseph Victor Garcia
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Carol Lvnn Kutcher
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
"";'~-VCC;H't""OOQf/,7PA'TtCl!N" ..r71r;'\:LAr"
B. TYPE OF INDUSTRY OR BUSINESS Fishkill Tire
5. PLACE OF BIRTH Poughkeepsie. NY
(CllY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Richard .John Strack
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marie Ann Bollella
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. 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?
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
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
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
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
y knowledge and belief that the information I provided IS true and tho declare that no legallmpee-exlsts
22. SIGNATURE OF BRIDE~ ~p u... ~l~-t. ~ -
fifx-. DATE 09/23/2009
by New York Domestic
w
(/)
Z
W
(.)
::;
MONTH
YEAR
22 2009
24
2009
11
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED ~
A. STATE NEW YORK B. COUNTY D I,;
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~pe.OFrf;
SPECIFYtJ (l~~'~^ ~~