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1. ,A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST RonaldtfoR!hony CS~W~'S~~AME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY nl Jtr.hAf'>f'>
CITYfTOWN W::lppingAr
~~~:~~ 1 :iRR
~~~I~J~R 107
-.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
IE'Ssili6bL~my Can~t9~~ SURNAME
11. A. FUll NAME
FIRST
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE r.sen/ak
(OPTIONAL - SEE REVERSE')'
D SOCIAL SECURITY NUMBER ORR- 7R-ORR9
12. RESIDENCE A, N"iSTATEl B D:d!~N9v)SS
C. CHECK ONE 0 CITY 1lI TOWN 0 VILLAGE
~~~CIFY E::lf'>t Fishkill
O. STREET ADDRESS 58 Cranberry Drive ZIP 12533
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 28 3B. DATE OF BIRTH gckH /1 ~AY /j' ~E~RO
14. EMPLOYMENT
A. USUAL OCCUPATION T A::lr.hAr~ A~~i~t::lnt
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH ~~rtSTSP/~~~~Y IF~ USA)
16. FATHER
A. NAME .IO~Arh Anthony r.::lnt::ltorA
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Christine C Flay
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
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER OR?-7?-RROR
2. RESIDENCE A. NYsTATE) 8. 9cY~E'SS
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY W::lrringAr~ F::lII~
D. STREET ADDRESS 8 Walker Place ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~ YES 0 NO
3. A. AGE 30 3B. DATE OF BIRTH MOQT~ / ~J / YWB-
4. EMPLOYMENT
A USUAL OCCUPATION prodllr.t Flow TA::lm
B. TYPE OF INDUSTRY OR BUSINESS Circuit City
5 PLACE OF BIRTH QI~I~TA7E'?6~U~RY ~~OT USA)
6, FATHER
A. NAME Ron;;.lrl Anthony r.c::prv::lk, ~r
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME EII::lmarie Kearns
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES -
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
o
o
o
o
o
o
o
o
o
o
o
o
21, SIGNATURE OF GROOM
W
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23. SUBSCRIBED AND SWORN AFFIRMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New k State the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perfoJTr marriage ceremonies within New York State, THIS L1CEN~E 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) J C. M
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ - DATE 08/15/2008
MAILING ADDRES AM 1 0
"-t-' STR~e9 Middl ush Rd. Wao~~,.;g;JS Falls'sT~r 1259~IP 02:26PM 08 16 2008 14 2008
~~~R~:Ri~~J IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY -
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ~IL
DATE AND AT THE TIME AND
PLACE INDICATED. 0 OTHER, SPECIFY
DATE
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ "'liD 'OW" 0' D '''CAG' 0'
SPECIFY ~Q '^-(. tfpi(. t(2S ,~
~
SIGNATURE~
SIGNATURE~
