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COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~c; 1368 .
~G~'~~~R 180
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Edward William Clark
MIDDLE CURRENT SURNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Antoinette Josephine Molinari
FIRST MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 7
D SOCIAL SECURITY NUMBER 119-54-63 5
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN..o VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 2791 West Main St; Apt 6 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? tJ YES 0 NO
09 /13 /1973
MONTH DAY YEAR
13. A. AGE 33
3B. DATE OF BIRTH
09
MONTH
3. A. AGE:i fi
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION CosmetoloQist
B. TYPE OF INDUSTRY OR BUSINESS Cosmetology
15. PLACE OF BIRTH Bronx, New York
(CITY , STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Ralph Jude Molinari
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Barbara Ann Rella
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
4. EMPLOYMENT
A, USUAL OCCUPATION HV AC Tech
B. TYPE OF INDUSTRY OR BUSINESS HV AC
5. PLACE OF BIRTH North Tarrytown. Ny
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
...
:>
c:(
A NAME Willi:::lm H Clark
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Margaret Kelly
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
n 0
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
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
o 0
o 0
o 0
o 0
ediment exists
i ..
o
o
o
o
est of my knowledge
o
o
o
21. SIGNATURE OF GROOM~
w
en
z
w
o
:i
USE RREN
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE 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 purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)3C ~
SEAL SIGNATURE~ ~.~ DATE 12/19/200
MAILING ADDRESS
"-v-' STRtJl Middlebush Rd, WaPR~'A-~rs FallsST~r 1259~p
~~~R~~~RT~~J 'O~O~~~N:::~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY /
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 0" CIVIL
DATE AND AT THE TIME AND AM
PLACE INDICATED. 3' CO M) I J. -S,\ J.U IS" 9 0 OTHER, SPECIFY
29. OFFICIANT'"! . ~c. " (' -,..r ;?1.0 '.J' I " I' r:: rt" .-.?
NAME (PRINT) J l)l..(~, . I I~, :::.; (C .) I TITLE f\1,t(4Z. .,..., t:. O\-l-l O.::-l '-
/ I I /-~ /,' . l '
SIGNATURE~ '-/1' ,=~?f /~ DATE i z. "1",lc.~?
MAILING ADDRESS .- ~
VI (i(~ ' fK/~ Illfe (; ~ () 5-"{ 0
STREET CITYfTOWN STATE
30. WITNESS TO CEREMONY I
NAME (PRINT) \( "", f\:L:2ff-'~P...l'\ Uli {\.....
SIGNATURE~ ~
DOH-98 (03/2006)
02
17 2009
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
YEAR
TIME
MONTH
11 :04AM
PM
12
20
2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 1.\1.,. iO{ e s 5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY w:,\M I N (, 8.'Z
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~