182
+
0",
en....
L{);"
Nen
...-
>-
Z
.... ~
ffiCJ) :;
~ro c(
~LL C
:5 CJ)'" u::
o ~'" U.
1Jj Q)~ c(
5 c
~ ._~
cr
Ii;
a
w
cr
w
Cl
<
ir
cr.
<
::;:
u.
o
W
I-
<
()
u:
>=
cr
w
o
w
cr
w
~
en
m
w
cr
"
"
<
~
B
w
D-
m
+
~~~ W
::>~-
t;;",~ ~
crcr- <C
Ii;~~ 0
::>ow
::;: Cl is u::
!z~m
~~15 ~
itom W
~~~ 0
~ffiLO
~~~
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~ 1368
~~~I~J~R 182
~ I #Ill I:: vr I~I:: YV , un"-
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
James Anthonv Rente
MIDDLE CURRENT SURNAME
(THIS SPACE FOR STA TE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christina Marie Blakslee
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
D-
N
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Renzo
(OPTIONAL. SEE REVERSEl057 -70-7952
D. SOCIAL SECURITY NUMBER
12 RESIDENCEA.NY B Dutchess
(STAlF) (COUNTY)
C. CHECK ONE '0 CITY 0 TOWN 0 VILLAGE;
~~~CIFY Beacon
D. STREET ADDRESS 192 Rombout Ave.
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)093 70' 9394
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY) .
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 40 Quarry Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
08 / 01 / 1984
MONTH DAY YEAR
ZIP 12508
'6
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 23 3B. DATE OF BIRTH 01 A 1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPAtiON Stay At Home Mom
B. TYPE OF INDUSTRY OR BUSINESS Home Maker
15. PLACE OF BIRTH Poughkeepsie, Ny
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Garv Fred Blakslee
'B. COUNTRY OF BIRTHU S A
YES 0 NO
)1'985
YEAR
3. A. AGE 24
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BUSINESS AccountinQ
5. PLACE OF BIRTH Poughkeepsie, Nv
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Raymond William Renzo
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Sheree Elaine VanTassel
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
17. MOTHER
A MAIDEN NAME Pamela Mary VanWagenen
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 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END?
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
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
rr:'
'"
'"
::;:
::>
z
"
z
<
....
'"
'"
~
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 right to enter into the ma~ge state.
21. SIGNATURE OF GROOM~;::::J.. 22. SIGNATURE OF BRIDE~
12/23/2008
W
en
z
W
o
::i
23. SUBSCRIBED AND SWORN TO/ FIRMED BEFORE
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 911 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o " 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
DATE
by New York Domestic
~
{ SEAL}
'-v-'
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DATE 12/23/2008
in ers Falls NY 12590
ITYIT WN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 0 RELIGIOUS
9 0 OTHER, SPECIFY
AM
02: 15PM
02
21 2009
2008
12
24
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 OCC~ _
A. STATE NEW YORK B. COUN~ r c.,~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF [j;<JILLAGE OF
SPECIFY wA,O~ ~t..tI ~
CIVIL
29. OFFICIANT
NAME (PRINT)
SIGNATURE~
DOH.98 (0312006)
SIGNATURE~