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COUNTY Dutchess
CITYtTOWN Wappinger
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Zachary Peter Carr
MIDDLE CURRENT SURNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ashley Lauren Lombardi
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
c..
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Carr
(OPTIONAL - SEE REVERSEtl95_76_7976
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE) J.. (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREETADDREss14 Nicole Dr.
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEI090_76_2832
o SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY WappinQer
o STREET ADDRESS 18 Top 0 Hill Rd. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tJ NO
12 /23 /1986
MONTH DAY YEAR
ZIP 1208U
DYES '6 NO
)'987
YEAR
3. A. AGE 22
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE22 3B. DATE OF BIRTH 04 /f8
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
B. TYPE OF INDUSTRY OR BUSINESS Hospital
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
16; FATHER
A. NAME David Thomas Lombardi
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Denise Cheryl Silverman
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MAARIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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4. EMPLOYMENT
A. USUAL OCCUPATION Actuarial Analvst
B. TYPE OF INDUSTRY OR BUSINESS Consulting
5. PLACE OF BIRTH Cortlandt, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Lawrence Spain Carr Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Heidi Jane Gardineer
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
- MONTH DAY YEAR
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
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
a:
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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 declare that no legal Impediment eXists
as to my nght to enter into the marriage tate..I, . ~
21 SIGNATURE OF GROOM~ ~ 22. SIGNATURE OF BRIDE~ ~NfJ!:d. /I ; .
USE CUR - f3E CUR ENT NAME
23. SUBSCRIBED AND SWORN TO/AFFI MED B RE ME OS/27/2009
SIGNATURE OF 1:0WN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Joh C. Mas erson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE OS/27/2009
"- -.J MAll..II)lGI-DDlaF.lEReS AM 05 28 2009 07 26 2009
-v- LU WI 01 ush Rd, Wappingers Falls, NY 12590 03:06PM
STREET CITY/TOWN STATE ZIP
~~~RJ~RT~~~ lo~O~~~N~zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 d'RELIGIOUS
DATE AND AT THE TIME AND.2 AM 0
PLACE INDICATED. U : 00 PM 01 9 0 OTHER, SPECIFY
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YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY\)U.tt..~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF []-1'QWN OF 0 VILLAGE OF
SPECIFY tH\.d + ~'iI' h\;; I ,
SIGNATURE~
DOH-98 (0312006)