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CITYfTOWNW::lrpinapr
~~~~~~Tj 3R8 .
~~~~:~R 1 Fi4
~"'" n" I IVI!::'" I ur- HeAL I H
AFFIDA VIT, LICENSE and
CERTIFICA TE OF
MARRIAGE
FROM THE GROOM
M.tth~~penn;s S~~URNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
r. hp;J;rYotf n n R en ~~~ENT SURNAME
1. A. FULL NAME
0-
N
FIRST
11. A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
FIRST
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCiAl SECURITY NUMBER 1 0 1-7? -Rq 1 ?
2 RESIDENCE A-NY B. -O(lltl"'h)ess
(STATE) <:b~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~gcIFY Ea<>t Fi<>"k:ill
D. STREET ADDRESS '27 \Nillnw nrivp. ~ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
MOU / JA~ / JE~R80
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Snri::lnn
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 092-74-2482
12. RESIDENCE Al'JY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY >It! TOWN 0 VILLAGE
~~fclFyNew Scotland
D. STREET ADDREss72 Maole Ave
ZIP 12186
o YES'6 NO
;(qn
YEAR
3. A AGE27
4. EMPLOYMENT
A USUAL OCCUPATION -Photographer
B. TYPE OF INDUSTRY OR BUSINESS Mp.rli::l
5. PLACE OF BIRTH \N"itE' PI~in~ f\J~
(CITY, STATE / COUNTA-f IF N T USA)
6. FATHER
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE~1 38. DATE OF BIRTH 01 A?
MONTH DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Editor
B. TYPE OF INDUSTRY OR BUSINESS Television
15. PLACE OF BIRTH~J'~~~~E / ~~NTRY IF NOT USA)
16. FATHER
A. NAMECh::lrlp.s I Ollis Renker' Jr
'B. COUNTRY OF BIRTHlJ S A
17. MOTHER
A MAIDEN NAME Susan Ann Bickel
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
A NAME .o~nni5 Anthony Soriano
8. COUNTRY OF BIRTH 1 J S A
7. MOTHER
A MAIDEN NAME P~lllpttE' l\A::lr~pll::l nnnnv::ln
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE j
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
~
DEATH
o
(2) 0 DEATH
8. 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
o
B. HDW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(3) 0 ANNULMENT (2) 0 DEATH
/ /
, . - YEAR
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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~= 0 0 ~,
I duly swear/affirm, defJose and say, that to the best of my knowledge and belief that the information I provided is t
as to my right to enter into the mage state.
21.SIGNATUREOFGROOM~ ~ 22.SIGNATUREOFBRIDE~
o 0
o 0
o 0
o 0
t no legal impediment exists
USE R
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New 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 cheeked, 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)
TIME
MONTH
YEAR
MONTH
YEAR
AM
03:34PM
01 2008
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10
03
2008
12
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY pvtc he.5.5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY Ftl S.t- r, s '^ \< \ \ \
NAME (PRINT)
SIGNATURE~
l'()...""-D
~
