107 0- N + >- Z W (/) W lD o ...J ::> o J: (/) Z o ~. 0 cr >- (/) a w cr w Cl <( ii cr <( ::! u. o w >- <( () ii: i= cr w () w cr W J: ;: (/) (/) w cr o Cl <( ~ C3 W 0- (/) cr' W lD ::! ::> Z o Z <( >- w w cr Ii; + Z~z !5_0 w >-;:i= ~ ll!reD! <c >-wZ !gd~ 0 ::!ClcS u: >-Z(/) ~~~ t: itO(/) W 0>->- w~15 0 b~"' z:o;; 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 en z W o :J 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~