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COUNTY nlltchE'S~
CITYrrOWN \N::lrrinop.r
~~J~kc: 1 ~RR .
~5~I:J~R R~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
ScoU;~[1drilw MC!Si~tURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
FIRST
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~ne MoniqJ~bt.polettp. Htu~E'JFsU~~~VFl
~
1. A. FULL NAME
11. A. FULL NAME
0..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~S~~~M~~~rt~W~~~s~cke\litt
D SOCIAL SECURITY NUMBER ROR-RR-2397
12. RESIDENCE A. NY B. nllt~hFl~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 12I TOWN 0 VILLAGE
~~~CIFY F::l~t Fi~hkill
D. STREET ADDRESs35 Country Club Road
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 144-74-6888
2. RESIDENCE A. N';(TATE) B. q~ilSS
C. CHECK ONE 0 CITY 42J TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS ~Fi r.nl mtry r.Ii Ih Rn::lrl ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? 0 YES ~ NO
MOara / J2$3 / y1i75
ZIP 12533
o YES~ NO
/1" q71
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE?
13. A. AGE 38 3B. DATE OF BIRTH nFi ~7
MONTH DAY
3. A. AGE 33
4. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS nr.c
5. PLACE OF BIRTH lerse~ Cit~Ttl t\I I
(CITY, STA / COU Y IF NOT USA)
6. FATHER
A. NAME Andrew ~kKe\litt
B. COUNTRY OF BIRTH II S A
7. MOTHER
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION M::lrkFltino M::ln::lop.r
B. TYPE OF INDUSTRY OR BUSINESS Eyewear
15. PLACE OF BIRTH Marseille1 France
(CITY. STATE I CUUNTRY IF NOT USA)
16. FATHER
A. NAME .Ip.::ln-I II~ AntninFl Pi::lttp.
'B. COUNTRY OF BIRTHErance
17. MOTHER
A. MAIDEN NAME Danip.lle Maryse Jane Macaradji
B. COUNTRY OF BIRTHErance
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
A. MAIDEN NAME Chri~tinE' M::lrk::lrt
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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
o
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ - YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
w
en
z
w
(,)
::i
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I d cl>>.re that no legal impediment eXists
as to my right to enter into th~rr ~t7:1! if
21'. SIGNATURE OF GROOM ~ 't'1"" LL..::l/ 22 SIGNATURE OF BRIDE ~
USE CUR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ ~
This license authorizes the marriage in New Yor 'State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11to 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
08/07/2009
~
{ SEAL }
'-.t-'
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
AM
12:26PM
10
06 2009
2009
08
08
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
l~L
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~IC~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~LLAGE OF_ 1/
SPECIFY &VfJr'1JPI ~ <l"tz.& 'F~
29. OFFICIANT
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~