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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christian Matthew Adel
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c; 1368 .
~5~I;J~R 11 2
1 . A FULL NAME
FIRST
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
ll.
N
B. BIRTH NAME. IF DIFFERENT
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Michelle Lvnn Chiumento
MIDDLE CURRENT SURNAME
.-J
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 129-70-3805
2. RESIDENCE A NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN'\O VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 7 North Gilmore Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES 0 NO
07 /08 /1984
MONTH DAY YEAR
3. A. AGE 24
3B. DATE OF BIRTH
11. A. FULL NAME
FIRST
4. EMPLOYMENT
A. USUAL OCCUPATION Restaurant Manager
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
5. PLACE OF BIRTH Pouahkeepsie. NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Ebrahim M. Adel
B. COUNTRY OF BIRTH EQvpt
7. MOTHER
A. MAIDEN NAME Denise Lucille DeSantis
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
o 0
DEATH
o
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Adel
(OPTIONAL. SEE REVERSE)1 04-68-8854
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWNtJ VILLAGE
~~~CIFYWappingers Falls
D. STREET ADDRESs? North Gilmore Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES 0 NO
~2 .%984
YEAR
13. A. AGE24
04
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
3B. DATE OF BIRTH
MONTH
DAY
YEAR
MONTH DAY
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
14. EMPLOYMENT
A. USUAL OCCUPATION Banker
B. TYPE OF INDUSTRY OR BUSINESS Banking
15. PLACE OF BIRTH Poughkeepsie, NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Ralph Philip Chiumento, Jr.
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Carol Ann Croushore
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. . ~ YEAR
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and s ,
as to my right to enter into the rrr
21. SIGNATURE OF GROOM. .
o
o
o
1ST
2ND
3RD
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork State of the bride and groom named above by any person authorized
W Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
en 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W { } NAME (PRINT) John C.
o TIME MONTH YEAR
::i SEAL SIGNATURE ~ . DATE 08/21/2008
'-- .-J MAIJJtl.G;'DDI)~E;l?
-v- LU wllam d, Wappingers Falls, NY 12590
STREET CITYITOWN STATE ZIP
~~~R~~RT~~~ IO~O!r~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR O"'/RELlGIOUS
DATE AND AT THE TIME AND ~
PLACE INDICATED. 9 0 OTHER, SPECIFY
DATE
by New York Domestic
MONTH
YEAR
01:19:~ 08
2008
10
20 2008
22
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COuw!!tJ vK..LI1N!)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 'p{ TOWN OF 0 VILLAGE OF
""",,26 (, '" G- VAl,
NAME (PRINT)
C::lnNATIIQI=.