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COUNTY Dutchess
CITYfTOWN \^'appinger
DISTRICT . .
~~~~~~R1368
NUMBER 136
~ I A I ~ ur I"~VV TUn",
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
St 'A/"II' C'
~[l v v I lam 'C~~T SURNAME
FIRST
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
S ~ldb!le Ca\'all~ENTSURNAME
..J
1. A. FULL NAME
". A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SDCIALSECURITYNUMBER 133 76 2245
2. RESIDENCE A. N'(sTATE) B. Q~~Cl3l3
C. ~~6CK ONE 0 CITY 0 TOWN~ VILLAGE
SPECIFY Wappingem F::llIs
D. STREET ADDRESS 7Q Mark8t Str88t ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? .j2] YES 0 NO
M~ /~O /~8
C. SURNAME AFTER MARRIAGE 0 i De
(OPTIONAL - SEE REVERS'Et
D. SDCIAlSECURITYNUMBER 128-78-7013
12. RESIDENCE ANY B.D'I+"'~ss
(STATE) 'tet'l!l/m'J
C. CHECK ONE 0 CITY 0 TOWN,j2J VILLAGE
~~~CIFY\j\/iilppingeri Falls
D STREET AODREss79 Market Btrp.p.t ZIP 1 ?!1~O
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ..tJ YES 0 NO
Q~H ~~AY -1 ~~~
13. A. AGE 1 9
14. EMPLOYMENT
3B. DATE OF BIRTH
3. A. AGE 20
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Electrical ^Gsombly
B. TYPE OF INDUSTRY OR BUSINESS Manufacturing
5. PLACE OF BIRTH ~~~ ~
( , 'tE / NTRY IF NOT USA)
6. FATHER
A. USUAL OCCUPATION Phl8botomist
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH \tcWf~+i\.PH~Ll~;:F NOT USA)
16. FATHER
A. NAME Robert Paul Ca'liillluZ1:i
B. COUNTRY OF BIRTHl I S A
17. MOTHER
A. MAIDEN NAME Kathleen Patricia Brennan
B. COUNTRY OF BIRTHll S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
~
:>
A. NAME Daniel Curtis Rice
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kristine Cialli
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
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
o
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
(3) 0 ANNULMENT
/ /
B. 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
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
o
o
o
i ent exiits
w
en
z
w
o
:J
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm. depose and say, th t to the best of my knowledge and belief that the information I provided is true and tha
as to my right to enter into the mar state, cc
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
U C
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M O~/1 O/?OOR
SIGNATURE OF TOWN OR CITY CLERK ~ DATE ____ ______
This license authorizes the marriage in New' of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremoni 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
DATE
YEAR
~
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
YEAR
TIME
MONTH
AM
06:57PM 09
2008
11
09 2008
11
SA
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY OV7C./rf$
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF)ir TOWN OF 0 VILLAGE OF
SPECIFY W ftf' If) Y)~ e- r
I' J
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
NAME (PRINT)
SIGNATURE~