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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Eric Jason Libero
MIDDLE CURRENT SURNAME
o 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
and belief that the information I provided is tr e a d that I declare t at no legal impediment exists
1ST
2ND
3RD
4TH
I duly swear/affirm, depose an~sa I that to
as to my right to enter into the nage 5t
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk 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) Jo n C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 10/22/2008
MAILING ADDRE~S 11 35AM
'-v-' 20 Middl ush Rd, Wappinoers Falls, NY 12590 : 10
STREET CITY/TOWN STATE ZIP PM
~~~R~~Ri~~~ IO~O~~~N~Z:~ 26 SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ~ CIVIL
DATE AND AT THE TIME AND I ' "i \ I '"
PLACE INDICATED. 0 . 0 ol S- 06 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~CRT1368
~~~I~~~R 164
1. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)559 95 4808
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A CA B. Oranoe
(ST A JE) (COUNTY)
C. CHECK ONE "'D CITY 0 TOWN 0 VILLAGE
~~~CIFY Anaheim
D STREET ADDRESS 619 North Ventura Street; ZIP 92801
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES 0 NO
3. A AGE 36 3B. DATE OF BIRTH 12 /29 /1971
MONTH DAY YEAR
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Megan Kathleen Lysko
MIDDLE CURRENT SURNAME
~
4. EMPLOYMENT
A. USUAL OCCUPATION Technician
B. TYPE OF INDUSTRY OR BUSINESS Textile
5. PLACE OF BIRTH Glendale, Ca
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME John Frederick Liberg
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Lillian Mvrl Dunn
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 11 / 11 / 2005
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~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
11/11/2005 San Bernardino, Ca d
DEATH
o
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Libero
(OPTIONAL - SEE REVERSE)1 07 -68-8534
D SOCIAL SECURITY NUM8ER
12. RESIDENCE ACA B. Orange
(ST~P') (COUNTY)
C. CHECK ONE '(] CITY 0 TOWN 0 VILLAGE
~~~ClFyAnaheim
D STREETADDREss619 North Ventura Street;
ZIP 92801
'6
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE31 3B. DATE OF BIRTH 01 ".a 1
MONTH DAY
YES 0 NO
,,%977
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Listing Rep
B. TYPE OF INDUSTRY OR BUSINESS Real Estate
15. PLACE OF BIRTH Long Beach, Ca
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Allan Edwin Lysko
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A MAIDEN NAME Patricia Anne Turner
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
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
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, OA Y, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
by New York Domestic
MONTH
YEAR
23
2008
12
21 2008
28. PLACE WHERE MARRIAGE OCCURRE~ ~ I
A. STATE NEW YORK B. COUNTY J....J1--h~ ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
-,i. CITY OF
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-98 (0312006)