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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Andre I<~Ja!pn Ashtof/:Jjg>>id3~sE
B. HOW DID LAST MARRIAGE END? (3) [!"DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 1 n/ 1 n / ?OOA
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 05/04/1990 Bermuda ~ 0 1ST
2ND 10/16/2008 Bermuda rf 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is tr e a
as to my right to enter into the marrrage s te. .
r- /.
21. SIGNATURE OF GROOM.
SE P1R
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME L '.
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the m.l}I'riage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform mp.rriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
M 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
COUNTY nlJtchp.~~
CITY/TOWN Wappinger
~~J:~CRT 1 368 .
~5~I:J~R 109
1 , A. FULL NAME
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
xxx-xx-xxxx
2 RESIDENCE A. B~HJW daB. (COUNTY)
c. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
ANO
SPECIFY RF'!rmllrl::l
D. STREET ADDRESS PoBox 249
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MO~~ / D1P / y1258
3. A. AGE 51
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Maril1E' Pilot
B. TYPE OF INDUSTRY OR BUSINESS Pllhlir. Transportation
5. PLACE OF BIRTH Panp.t 1~I::lnrl. Rp.rmlld::l
(CITY:'STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME EllgenE'Tl17n
B. COUNTRY OF BIRTH Rerml Ida
7. MOTHER
A. MAIDEN NAME Mary F Hollinsid
B. COUNTRY OF BIRTH Rermllrla
8. NUMBER OF THIS MARRIAGE 3
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
? n
DEATH
o
W
tn
Z ,-;-...
~ { } NAME (PRINT)
:J SEAL SIGNATURE ~
MAILING ADORES
'-.,-I .
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
SIGNATURE~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11.A. FULLNAME FIRST NetterMfoJtr::lheth ThC~~~~URNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Da\lis
c. SURNAME AFTER MARRIAGE I-lollinsid
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 158-54-4694
12. RESIDENCE A. NY B. nlltr.he!=;.!=;.
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN \ZJ VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS Unit 19-1f Vandidoort Dr.
ZIP 12524
~YESONO
A q!1R
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 52 3B. DATE OF BIRTH 1 n ,.,.., 1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Ther::lri~t
B. TYPE OF INDUSTRY OR BUSINESS Human Services
15. PLACE OF BIRTH Bridaeton, NJ
(CITY. ~ATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Frlrlip. n::lvi~
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Sarah Pennington
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
001
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~ DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 24 / 1985
MONTH flAY' ~ - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES I!I 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
that I declare that no legal impedime t exists
22. SIGNATURE OF BRIDE.
-lax....-
by New York Domestic
TIME
MONTH
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
DAY
YEAR
YEAR
MONTH
11 :34AM 09
PM
11
15 2009
17
2009
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
J
A. STATE NEW YORK B. COUNTY! Vc-f f1O< 011I\
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF u:;K1ILLAGE OF
SPECIFY L G/~ ~/) f" /Klr
~y
/