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COUNTY Dutchess
CITYffOWN Wappinger
~~J:~c; 1368 '
~5~~J~R 99
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mi~h::lp.1 FI::lmin .Ir
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
A">>'DD~~an MoraPu~RENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER . 088-52-8268
2. RESIDENCE A. NY B. 01 Jtr.hp.~~
(STATE) . (COUNTY)
C. CHECK ONE D CITY iZI TOWN D VILLAGE
AND W '
SPECIFY applnger
D. STREET ADDRESS 1611 Route 376 Apt. 25 ZIP 12590
E. IS RESIDENCE WlllilN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
3. A. AGE 37 3B. DATE OF BIRTH 10 / 1!) /1971
MONTH DAY YEAR
4, EMPLOYMENT
A. USUAL OCCUPATION C:omplltp.r Software. Designer.
B. TYPE OF INDUSTRY OR BUSINESS Music Matrices .
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Mich::lp.1 Rocco FI::ll')1io
B. COUNTRY OF BIRTH USA
7. MOTHER
A, MAIDEN NAME Kathleen Marie Smith
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~~RMtFR~~'E<vr8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE FI::l m io
(OPlIONAL. SEE REVERSE) 2 231
D. SOCIAL SECURITY NUMBER 124-7-4
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY.11!'I TOWN D VILLAGE
~~~CIFY Wappinaer
0, STREET ADDRESS 1611 Route 376 Apt. 25
ZIP 12590
DYES '6 NO
/1'979
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE?
13, A, AGE 29 3B, DATE OF BIRTH 09 /21
MONTH DAY
14. EMPLOYMENT
A, USUAL OCCUPATION Booker
B. TYPE OF INDUSlRY OR BUSINESS AccountinQ
15. PLA~E OF BIRlH Thief River Falls, Mn
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Terry Gordon Dunham
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Kavle Reen Brandt
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE .3
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
c. DAlE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
19. ~~~~~~?RMtFR~~E<tJf8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) D ANNULMENT (2) D DEATH
C. DAlE LAST MARRIAGE ENDED? 07 / 13 / 2009
MONTH DAY' . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? iY YES D NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMAllON
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
09/13/2005 PouQhkeepsie, NY 0 tf
07/13/2009 Poughkeepsie, NY D ~
D D
o D
no legallmpedimeht exists
DEATH
o
DEATH
o
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO.
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE lHE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into th m
21. SIGNATURI; OF GROOM ~
1ST
2ND
3RD
4TH.
the information I provided 's tr
23. SUBSCRIBED AND SWORN lO/AFFIR
SIGNAlUREOF lOWN OR CITY OLE
This license authorizes the marriage in New' York State of the de and groom named above by any person' authorized
Relations Law ~l1to pertorm marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license ;S to be used only for the purpose of a second or sUbsequent ceremony.
r-I'-.. 24. TOWN OR CITY CLERK 25. A. S.OLEMNIZAlJON PERIOD BEGINS
} NAME (PRINT)' 0 n .
{ ~ ~ ~
SEAL SIGNAlURE~ DATE 09/01/200
.~ MAI~~ tJi~ S ers Falls NY 12590 .09 02 2009
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
lHE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 D RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDIC 9 D OlHER, SPECIFY
MONlH
YEAR
10. 31 2009
28. PLACE WHERE MARRIAGE OCCU~ ._
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
D CITY OF D TOWN OF M"VILLAG~F.. JJII
SPECIFY wf\ff/~~ ~
NAME (PRINT) .
SIGNATURE~
SIGNATURE~