111
+
N
o
~
f'--w
..-1-
..
I-
If)
<(
0...
.::t:.
....0 I-
~>- :>
CJl <
iilN C
o _
s';wu.
o "u.
1}j<(~<
Z . ~
g.;:.~
~Ol:::
!!i CO 5
fil c
~.Q
ClCJ)
:! CJ)
~2
~ 0
u. ....
oa..
t:!-c
.. ....
f,? 0
~'t
ffi Q)
u_
w co
a:
w
~
CJl
CJl
w
a:
o
Cl
..
i::
u
w
"-
CJl
0:'
W
'"
::!
:J
Z
o
~
I-
W
W
~
+
~:i:z
::>t:Q
liJ~~
~ffi2
CJl-,=>
::>uw
=>"c:
I-ZCJl
~5u..
o~o
~O(J)
01-->
Ui~~
b~'"
z3g
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:kc~ 1368
~~~I::~R 111
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
!=:tpf::m .Inhn \Inn !=:tpin
MIDDLE CURRENT SURNAME
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
AshLl(Jti\nne Velli~~ENT SURNAME
~
1. . A FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE \Inn StAin
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 108-68-3839
12. RESIDENCE A P A BY ork
(STATE) (COUNTY)
C. CHECK ONE 0 CITY >(J TOWN 0 VILLAGE
~~~CIFY York
D. STREET ADDREss1 Waterford Professional
z,P17402
o YES "6 NO
;(984
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 059-74-6444
2. RESIDENCE A. P::l B Y nrk
(ST ATE) (COUNTY)
C CHECK ONE 0 CITY.,(J TOWN 0 VILLAGE
~~~CIFY Y nrk
D. STREET ADDRESS 1 Waterford Professional ZIP 17402
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YESo(] NO
05 / 1R /1~R4
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE?4 3B. DATE OF BIRTH 04 A51
MONTH OA Y
3. A. AGE24
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Prnjp.r.t F!=:tim::Jtnr
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH RivArhead, N~
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME r.::Jrl FI1op.np. \Inn StAin
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Jacqueline Sacco
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
14. EMPLOYMENT
A. USUAL OCCUPATION Therapuetic Staff Support
B. TYPE OF INDUSTRY OR BUSINESS Human Services
15. PLACE OF BIRTHCity Of Poughkeepsie
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEArthur David Venier
'B. COUNTRY OF BIRTJ.1 S A
17. MOTHER
A. MAIDEN NAME Marion Jeanette Nolen
B. COUNTRY OF BIRTJ.1 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
(2) 0 DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END?
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
w
en
z
w
o
::i
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, dej:lose and say, that to the best of my knowledge and belief that the information I provided is true and that I
as to my right to enter into the marn5:J!.a~
21. SIGNATURE OF GROOM~ ~ V~ 22. SIGNATURE OF BRIDE~
~ US~CURR NAME
23. SUBSCRIBED AND SWORN 'I'Cl/AFFIRMED BEFORE ME ~ A ( A4 /J ~ / .. ^
SIGNATURE OF TOWN OR CITY CLERK ~ _ ..I 4;,,!. :::::z.....t.J.&!...1!:..4.. "'"
This license authorizes the marriage in New York 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
o 0
o 0
o 0
o 0
legal impediment exists
by New York Domestic
~
{ SEAL }
"-v-I
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
SIGNATURE ~
MAILING ADDRESS
20 Middlebush Rd.
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
09:35 AM 08
PM
20 2008
2008
10
22
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Mc.k.es s
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLA~E OF 1 JC.I
SPECIFY 1b~ h k-e-r:r!:;~/e) T
S ET I , I
30 WITNESS TO CEREMONY ~~' J ,
NAME (PRINT) j.~" 1/1 --~ ----
SIGNATURE~ ~li
SIGNATURE~