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COUNTY Dutchess
CITYfTOWN \^Jappinger
DISTRICT .
NUMBER ~ :366
REGISTER
NUMBER 105
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Br~1itoMichacl LQU~T SURNAME
FIRST
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tere~AIIarie Blar1Q~~ SURNAME
-.J
1. . A. FULL NAME
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 100 66 1903
2 RESIDENCE A NYsTATE) B QytQACGC
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND
SPECIFY E3€t Fishkill
D. STREET ADDRESS 91 \j\/oodcrest Dri\le ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
M~ / r1Q /~4
C. SURNAME AFTER MARRIAGE I 3m n
(OPTIONAL. SEE REVERS'/!)
D. SOCIAL SECURITY NUMBER 088-76-0166
B.DlJM;;~ss
VILLAGE
12. RESIDENCE A,NY
(STATE)
C. CHECK ONE 0 CITY.j2I TOWN 0
AND [") II '
SPECIFY rOl.lghr:..eepsle
D. STREET ADDRESs67 Vera Drh/P ZIP 1 ?Rn:i
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
Q;6.TH /-) gAY l' ~~~
3. A AGE 24
4. EMPLOYMENT
3B, DATE OF BIRTH
13. A AGE21
14. EMPLOYMENT
3B. DATE OF BIRTH
A USUAL OCCUPATION Graduate Student
B. TYPE OF INDUSTRY OR BUSINESS Mercy Colleg€l
5 PLACE OF BIRTH ~~~i~'N~YSA)
6, FATHER
A. USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BUSINESS Accollnting
15, PLACE OF BIRTH ~c~~ht~5~\~~F'N~~SA)
16. FATHER
,A. NAME Dennis Michael Blandino
B COUNTRY OF BIRTHII S A
17. MOTHER
A. MAIDEN NAME Nancy lean Post
B. COUNTRY OF BIRTHll S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A NAME Michaal Morris L3ffin
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Betty Jean Th€lysohn
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGESWHlCH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
o
o
(3) 0 DIVORCE
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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 0 0 1ST 0
fr' 2ND 0 0 2ND 0
w
lD 3RD 0 0 3RD 0
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.... 21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFO E
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
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
DATE 08/1 :i/?008
by New York Domestic
~
{ SEAL }
~
NAME (PRINT)
YEAR
TIME
MONTH
YEAR
MONTH
DATE
AM
05:29 PM 08
14
2008
10
12 2008
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SA
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
P
28. PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B. COUNTY"jJ,..4. fJ'I'l'S5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECI~ ~ ~ h /: er;,,(l S ,'e.--
10 CIVIL
DATE
STATE
ZIP
31, WITNESS TO CEREMONY
\1) ~ i '^
NAME (PRINT) '.' ",., , "
f1 /~~
f'. .\
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30 W1TNESS TO CE~NY 'u
:::::::: (::G, ~L 4 )~~
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SIGNATURE~