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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Benjaw~ Franklin PuitWCtWJaE
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
st of my knowledge and belief that the Information I provided is true and that I declare that no legal impediment exists
22 SIGNATUREOFBRID~~A~~~
us ~ USE CURRENT NA
23 ~:J..fT~~~DO~N-?O~~O~~ ~~Abr~~E~ BEFORE ME OAT /2008
This license authorizes the marriage in New ork State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 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
COUNTY
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
\^'appinger
1368
151
1 . A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 556-63-1942
2. RESIDENCE A. IIJY B r\ut.cl.-.ess
'(!;T'ATE) . (etll)fltTj' I I
C. ~~5CK ONE 0 CITY 0 TOWN 01 VILLAGE
SPECIFY \^'.ppingeroa Falls
D STREET ADDRESS 22 Clapp A \lP; 1!=:t Flnnr ZIP 1 ?!=;qn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Dv'YES 0 NO
3. A. AGE 28 3B. DATE OF BIRTH MONr02 / DA~3 / YE~98
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Restallrant
5. PLACE OF BIRTH (C/'.P~A~ ~~l~y~~ N~~SA)
6. FATHER
A. NAME Herald Ben Patterson
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Kathleen Lorraine Wilson
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
....
'"
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (31 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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to th
as to my right to enter into the marriage st.
21. SIGNATURE OF GROOM~
~
{ SEAL }
'-v-'
., I A I C. rlL..c ....UMDCM
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lb%m}4arie M~NT SURNAME
~
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SVS~~m:N~~~~~t~~b~~SE) Patterson
o SOCIAL SECURITY NUMBER 1 ~ 1-7 4-!1 1 ?!=;
12. RESIDENCE A. N(~ATEI 8. QMt~ess
C. CHECK ONE 0 CITY 0 TOWN D,/VILLAGE
~~~CIFY W~rrinopr!=: F~II!=:
D. STREET ADDRESS ?? CI::lpp Ave; 1 st Floor ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [Jo"VES 0 NO
13. A. AGE 2Q 3B. DATE OF BIRTH M~~ / JA9 / JE~l9
14. EMPLOYMENT
A. USUAL OCCUPATION Sales Manager
B. TYPE OF INDUSTRY OR BUSINESS T::lp Kwon no
15. PLACE OF BIRTH Pnllnhkppn!=:ip Nv
(CITY, STATe / COUNT!lY IF NdT USA)
16. FATHER
A. NAME Palll Manzo
B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME I inrl::l M::lrip I ::lffin
B. COUNTRY OF BIRTH I I S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
n
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
TIME
MONTH
NAME (PRINT)
YEAR
MONTH
YEAR
AM
01:0~
10
02
200
11
30 2008
I frO
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
SATE
27. TYPE OF CEREMONY
o ~ELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ?",t-t.-k.>J
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY F/~ j, X/ 1/
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
/ II oj ~OO~
29. OFFICIANT ~If jJ.lIUv . r\ 0 D. I IV 1.0 ,1'1
NAME (PRINT) ---.., P :!;!.
SIGNATURE ~ 1:.1- Itnl--
MAILING ADDRESS . , -l
~ NWh.(.."1 (.,T ~,Jlte a W~tD()fnt:NJ(J
STREET 1f CITYfTOWN H--:r-
A11-sro [)
TITLE 1\
I{.-I .;llJO~
DATE
NY 1d.5'90
STATE
SIGNATURE~
DOH-98 (03/2006)
31.
NAME (PRINT)
SIGNATURE~