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\..fVUI\l1 T UUl~IIt::~~
CITYiTOWN \j\/appinger
~~~:~; 1368
REGISTER ..,
NUMBER 94-
Ut:t"'Ati I Mt:I'II1 UI"" Mt:I-\L 1M
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
P~!ERol:md JbtJ~~ENT SURNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
A.ls~~~atrics Q~~~TSURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
o SOCIAL SECURITY NUMBER 055 74 4793
2. RESIDENCE A. NV B. 1""\, .+"heSE:
(STATE) ~
C. ~~6CK ONE 0 CITY I;jl TOWN 0 VILLAGE
SPECIFY East Fishkill
D STREET ADDRESS 8 Sycamore lane ZIP
E. is RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? 0
MO~/~
C. SURNAME AFTER MARRIAGE loll"
(OPTIONAL - SEE REVERS~ J
D. SOCIAL SECURITY NUMBER 069-74-0107
12 RESIDENCE A. N'(STATE) B. D~!&:f;wss
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 8 ~yr.~mnr*" I ~n*" ZIP 1 ?FiT~
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED ViLLAGE? 0 YES ~ NO
Q~TH ~~AY /-f ~1
1253~
YES ~ NO
/ yli81
A. USUAL OCCUPATION Cabls'lision
B TYPE OF INDUSTRY OR BUSINESS Communications
5 PLACE OF BIRTH FcrR~~~o~AAi~No!iJ~A)
6. FATHER
13. A. AGE 24
14. EMPLOYMENT
A. USUAL OCCUPATION Secret.ry
B. TYPE OF INDUSTRY OR BUSINESS Correctinns
15. PLACE OF BIRTH Sharon Ct
(CllY, STATE I COUNTRY IF NOT USA)
16. FATHER
3B. DATE OF BIRTH
3. A. AGE 27
4. EMPLOYMENT
3B. DATE OF BIRTH
A. NAME D3\Jid R Jolly
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Adele Tannini
8. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
,A. NAME Philip Joseph Ql.linci
B. COUNTRY OF BIRTH I I S A
17. MOTHER
A. MAIDEN NAME Tp le1i Arm Frl1enrlt
B. COUNTRY OF BIRTH Morocco
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
o
o
(2) 0 DEATH
o
o
o
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
8. 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
C. DATE LAST MARRIAGE ENDED?
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 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare t
as to my right to enter into the~arflage state. .
21. SIGNATURE OF GROOM ~ ~ W 22 SIGNATURE OF BRIDE ~ .
23 SUBSCRIBED AND SWORN TO/AFFIRME~ B~ORE ~iE C ()-....
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 911 to perlorm marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK Sl1ATE 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) I ~f9..-C M11t~OD
{SEAL SIGNATURE ~ 1L C:l>.VP J.L~ DATE 07/30/2008
MAILING ADDRESS
'-v-I STRt>> Mirlrll*"hll~h Rrl, W~rR~~t; F~II~sT~TEY 1 ?592p
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TI MO. DAY YEAR 00 RELIGIOUS
DATE AND AT THE TIME AND I
PLACE INDICATED. 9 0 OTHER, SPE~
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
09
28 2008
07
31
2008
28. PLACE WHERE MARRIAGE OCCURRED ~
A STATE NEW YORK 8. COUNTY \) /t '> ~
LOCATION OF CEREMONY
(CHECK ONE AND YEC1FY)
o CITY OF ip'fOWN OF 0 VtLAGE OF
SPECIFY t) \.> \0 -IV V ~ J
o \rJC I
SIGNATURE ~
DOH.9B (0312006)