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1. A. FULL NAME
~ I "" I &;. ur I~&;' VV I unn.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JOSel2h Beniamin Landsman
FIRST MIDDLE CURRENT SURNAME
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368
~5~I:J~R 42
~
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Antoinette Cavellero
MIDDLE CURRENT SURNAME
11. A. FUll NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)061 80 5167
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY'o(] TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 283 Town View Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"'lJ NO
3. A. AGE 26 3B. DATE OF BiRTH 07 / 04 / 1982
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Landsman
(OPTIONAL - SEE REVERSEl051_7 4-4901
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREETADDREss283 Town View Dr
ZIP 12590
DYES '6 NO
;1'983
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 25 3B. DATE OF BIRTH 06 A)9
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Programer
B. TYPE OF INDUSTRY OR BUSINESS Software
5. PLACE OF BIRTH Rhinebeck, Nv
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Selig Moses Landsman
B. COUNTRY OF BIRTH Germany
7. MOTHER
A. MAIDEN NAME Martha Anne DiesinQ
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
14. EMPLOYMENT
A. USUAL OCCUPATION Human Resources
B. TYPE OF INDUSTRY OR BUSINESS Consumer Products
15. PLACE OF BIRTH Yonkers, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard John Cavellero
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Susan Marie Izinicki
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 OEATH
/ /
- YEAR
MONTH DAY YEAR
O. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE ENO? (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
1ST 0 0 1ST
2ND 0 0 2ND
3AD 0 0 3AD
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 true and that I declare that no
as to my right to enter into the marriage state. c---'7 ~
21. SIGNATURE OF GROOM ~ ~-
o 0
o 0
o D
o 0
I impediment exists
USE CUR
23. SUBSCRIBED AND SWORN TO/AF MED BEFORE ME
SIGNATURE OF TOWN OR CITY ERK ~
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 urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE 05/15/2009
by New York Domestic
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
~ MAI~~~fR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
MONTH
YEAR
YEAR
TIME
MONTH
03:20~~ 05
142009
16
2009
07
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYl) v-k ~ s S
C. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF p-'TOWN OF 0 VILLAGE OF
SPECIFY~(l)w-\i \c"-t.e.. ~\-f'
NAME (PRINT)
SIGNATURE~