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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c;1368
~5~~J~R36
_.,..,..- -.
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian Thomas Johnson
MIDDLE CURRENT SURNAME
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb58_66_4002
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYotJ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS P.o Box 931
3. A AGE28
ZIP 12590
YES"6 NO
/1981
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
01 /10
MONTH OA Y
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH North Terry town, New York
(CITY, STATE / COUNTRY IF NOT USA)
....
:;
c(
6. FATHER
A. NAM~ John T. Johnson
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Emily Louise Grant
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
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
. -. ..,
I".......... I......... , ...... ......,..- .......- .........'1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Stephanie Ann Carmalitano
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Johnson
{OPTIONAL - SEE REVERSE084-68-9207
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A.NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK ONE Q CITY U TOWN 0 VILLAGE
~~~CIFY Wappmger
D. STREETADDRESS9U All Angles Hili Kd,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE26 3B. DATE OF BIRTH 04
MONTH
14. EMPLOYMENT
A USUAL OCCUPATION Customer Service
B. TYPE OF INDUSTRY OR IilUSINESS.OII Company
15. PLACE OF BIRTH PoughKeepsie, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Vito James Carmalitano
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Deborah Ann Tomlins
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL AOULMENT
Dl1TH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
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 0
o 0
o 0
o 0
at no legal impediment exists
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that
as to my right to enter into the marnag
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
of my knowledge and belief that the information I provided is tru
23. SUBSCRIBED AND SWORN TO/AFFIRMED B FO
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 by New York Domestic
Relations Law 911 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) Jo .
{ 05/11/2009 TIME MONTH YEAR MONTH
SEAL SIGNATURE" E
'-v-I MAI~~G~fcr~T ers Falls, NY 12590 03:27~~ 05 12 2009 07 10 2009
STREET CITYrrOWN STAT ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
~~~SM~~~~:"B~vJ~N PitfE TIME MO. DAY YEAR 0 ff'RELIGIOUS
DATE AND AT THE TIME AND 1_ '3 AM
PLACE INDICATED. IP, 0 05 ~ '3> D'1 90 OTHER, SPECIFY
~~J>t(~~~TRev, fGffLhl .:J. A-m/JI.;'/)5~N TITLEMr~TIf /iI/A//sre,e
SIGNATURE" ~ ev '<;( iL-:r, A->--- DATE Mil- Y .;23, ~() 09
MAILING ADDRESS \ /7 _ LI .
.;23 (<.J'btJ,CI/IG'W IlP~ ti~f?e1f/~U JtJ,va'iCAJ j Nf./ I &J533
STREET CITYfTOWN STATE'
30. WITNESS, 31. WITNESS T
USE CURRENT NAME
05/11/2009
DATE
YEAR
26. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY'Du7'clie'~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY U./ fh:/tJl Al &, m
i//L-U/- &~/IiZ E
NAME (PRINT)
SIGNATURE"