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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~CRT1368
~5~~l~R 50
;) . A . I:. Ur- .,,1:. VV T Utlr\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Victor L Bernabo, JR.
MIDDLE CURRENT SURNAME
CURRENT SURNAME
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dawn M Mead
-1
1. A. FULL NAME
11. A FULL NAME
FIRST
FIRST
MIDDLE
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl113_62_3871
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYootJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 29 A Hudson View Dr, ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"D NO
3. A AGE43 3B. DATE OF BIRTH 08 /29 /1965
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mead-Bernabo
(OPTIONAL. SEE REVERSE!263_75_9862
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE).L (COUNTY)
C. CHECK ONE ~ CITY U TOWN 0 VILLAGE
AND F' hk'
SPECIFY IS I
D. STREET ADDRESf9 A Hudson View Ur.
14. EMPLOYMENT
A. USUAL OCCUPATION Paralegal
B. TYPE OF INDUSTRY OR BUSINESS Legal
15. PLACE OF BIRTHPoughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
ZIP 12bOts
o YES~ NO
;1'965
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE44 3B. DATE OF BIRTH 04 ~1
MONTH DAY
4. EMPLOYMENT
A USUAL OCCUPATION Operator Enoineer
B. TYPE OF INDUSTRY OR BUSINESS Local 137
5. PLACE OF BIRTHPeekskill, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME Victor L. Bernabo Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Elizabeth Anastasi
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
16. FATHER
A. NAME Ronald Alvah Mead
B COUNTRY OF BIRTJJ S A
17. MOTHER
A MAIDEN NAME Alice Lee Butler
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEkTH
1 0 U
B. HOW DID LAST MARRIAGE END? (3) t:J DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (O~ DEATH
C. DATE LAST MARRIAGE ENDED? 12 / 17 / 2003' c. DATE LAST MARRIAGE ENDED? 11 / 23 / 20
MONTt\,o DAY YEAR MONTiIo' DAY ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? i:i YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? tJ YES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
12/17/2003 Pouohkeepsie, New York t1 0 1ST 11/23/2004 Poughkee sie, New York 6
02/07/1990 Poughkeepsie, New York ~ 0 2ND
o 0 3RD
o 0 4TH
e and belief that the Information I provide
DEATH
o
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into th~ rr
21. SIGNATURE OF GROOM ~ -...l
S U
23. SUBSCRIBED AND SWORN TO FFIRMED B FORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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 purpoBe of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masterson
{SEAL SIGNATURE ~ {)Q c:.:tJJ..~ DATE OS/28/2009 TIME MONTH YEAR
'-v-I MA~5GlOWcfaf~~~sh Rd, Wappingers Falls, NY 12590 10:50AM 05 29 2009
STREET CITYITOWN STATE ZIP PM
~~~~:RT~~lIO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
by New York Domestic
MONTH
YEAR
07
27 2009
1 ~ CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY()\fi't~~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECI~'N(j'f~\t'\~r~ F;J \,s
NAME (PRINT)
SIGNATURE~