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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tim~M S. TcmPtQ~lAisuRNAME
o
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTP6 / Q.~ . (. ~g~3
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
.
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH. DAY. YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
01.'1"1.'2006 Poughk~~psi~, Ny 0 IitJ' 1ST 06/09/2003 POllohlcppr!::ie, NY Ii1'l
o 0 2ND 0
o 0 3RD 0
o 4TH 0
e and belief that the information I provided is true n nt exists
23. SUBSCRIBED AND SWORN T /AFFIRMED
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk 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
} NAME (PRINT) ~ r-.~~OJ"l
{SEAL SIGNATURE ~ (: ~:~- ~ DATE 08/20/2008 TIME
MAILING ADDRESS AM
"-v-' STR~ Middlebllsh Rd, '^'apg+OO~J~ F::lII!::'shI;r 1 ?!1q~IP 05:25 PM 08
~~~R~~~RT~~~ 10~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ~VIL
DATE AND AT THE TIME AND 8 _I ")
PLACE INDICATED. C7 'l t;oloo8' 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN '^'appinger
DISTRICT . .
~~~I~~~R1368
NUMBER 1 09
1 A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 116 62 9223
2 RESIDENCE A. NYSTATE) 8 qM~PGC
C CHECK ONE 0 CITY 0 TOWNJ] VILLAGE
AND
SPECIFY \Nappingers Falls
D. STREET ADDRESS 11 S. Gilmore BI\ld ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? eJ YES 0 NO
M~ / ao / ~9
3. A. AGE 38
4. EMPLOYMENT
38. DATE OF BIRTH
A. USUAL OCCUPATION Carpenter
B. TYPE OF INDUSTRY OR BUSINESS Construction
5 PLACE OF BIRTH Q~~~~tl~h)
6. FATHER
A NAME La'.vrenoc C. Tempectilli
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Grace Casamassima
B. COUNTRY OF BIRTH Italy
8. NUMBER OF THIS MARRIAGE 2
9. PREV~US MARRIAGE8
A. NU 61~g~tlREVJ JJS MARRIAG6it~'A'~~uT.~~m BY
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) Iil! DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / 14 / ')n.08
MONTH DAY '!'E:Jj!i
D. ARE ANY FORMER SPOUSE(S) ALIVE? Iii1YES 0 NO
1
1ST
2ND
3RD
4TH
I duly swear/affirm. depose and
as to my right to enter into
29. OFFICIANT
NAME (PRINT)
TITLE
DATE
?=A:l\ S
SIGNATURE~
DOH-98 (03/2006)
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
'I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Na~Lt.nn Burkijf~ENT SURNAME
~
11. A FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c SYS~~M~E~rEA~~~~As1;empestilli
D SOCIAL SECURITY NUMBER 093-64-6590
12. RESIDENCE ANY B. D' ,t,..h",SS
(STATE) iroCf:mI
C CHECK ONE 0 CITY 0 TOWN,jlJ VILLAGE
~~~cIFY'^'appingers Falls
D. STREET ADDREss11 ~ ~ilmnrp Rlvrl ZIP 1 ?!1QO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? olJ YES 0 NO
Q~TH /-f '&AY l' ~l~
13 A AGE32
14. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Hardw::lrE"
15. PLACE OF BIRTHManhassat NY
(CITY. STATE / COUmRY IF NOT USA)
16. FATHER
3B. DATE OF BIRTH
. A. NAME George R. Burk.rd
B. COUNTRY OF BIRTf-i I S A
17. MOTHER
A. MAIDEN NAME Mona D Hemrc::.nn
B. COUNTRY OF BIRTf-i J S A
18. NUMBER OF THIS MARRIAGE ?
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
1
o
22. SIGNATURE OF BRIDE~
by New York Domestic
MONTH
YEAR
MONTH
YEAR
21
2008
10
19 2008
28. PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B COUNTY b\)T~esS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY
1;)f\N'{N6 E:.r<-
SATE