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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
D:::lr~L~offrey Lieon!:WSURNAME
COUNTY Dutchess
CITYfTOWN \l\Iappinger
DISTRICT 68
NUMBER 1 3
~~~~J~R 90
1. ,A. FULL NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 091 78 0314
2 RESIDENCE A. NV B. n, .+,..h05S
/STATE) ~,
C ~~6CK ONE 0 CITY,j;tI TOWN 0 VILLAGE
SPECIFY Wappinger
D STREET ADDRESS 150 Carnaby Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES oIZI NO
3. A AGE 24 38 DATE OF BIRTH MOoa / 011 / y1,2S3
4. EMPLOYMENT
A. USUAL OCCUPATION Delayed Entry Program
B. TYPE OF INDUSTRY OR BUSINESS United States Na\lY
5. PLACE OF BIRTH ~IW~t~J;J9Iri~USA)
6. FATHER
A. NAME Jeffrey Thomas Lisman
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Connie Jo Leonard
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGESWHIGH .ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Andreio~rolina D~ttURNAME
--.J
o
o
o
(2) 0 DEATH
11. A. FULL NAME
FIRST
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. S~S~*~N~~E~~t~~C~~sQorado Lisman
D. SOCIAL SECURITY NUMBER 096-76-1155
12. RESIDENCE A. NXSTATE) B D\tb~ss
C. CHECK ONE 0 CITY l;il TOWN 0 VILLAGE
AND ^' .
SPECIFY \ applnger
D STREET ADDRESS 1 ~n r.::lrn::lhy ~trF!F!t ZIP 1 ?~!=l0
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 23 38 DATE OF BIRTH g~TH ~gAY ~ W~;;
14. EMPLOYMENT
A. USUAL OCCUPATION LPN
B. TYPE OF INDUSTRY OR BUSINESS He::llth r.::lre
15 PLACE OF BIRTH ~1~~l~A~2~~~NT~y9~~gT<i~~
16. FATHER
A. NAME Alberto Dor.do
B. COUNTRY OF BIRTHColomhi::l
17. MOTHER
A. MAIDEN NAME Grece Petri~i::l Fn~::;JI::lde
B. COUNTRY OF BIRTHEcllednr
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
MONTH OA Y 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH OA Y 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
22. SIGNATURE OF BRID
o 1ST
o 2ND
o 3RD
o 4TH
nd belief that the information I provided S tru
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEF
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 StatB. 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
r-^-..
{ SEAL }
'-.t-I
NAME (PRIND
DATE
07/1 R/?OOR
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
05:07PM
2008
09
14 2008
07
17
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
ClFyl))A-t/PI ~
NAME (PRIND
SIGNATURE~