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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 Matth~w'L?tE'\Ien H~IM~1:l9J;lNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY nIJtr.hA~~
CITYfTOWN Wappinger
~~~:kc~ 136R
~~~I~~~R 88
~
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
lessic~ ~n"e Me r.~~~m~
D LE C T URNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER ?41-!=i3-n~n 1
2. RESIDENCE A. N~TATE) B qcld~W;1
C. CHECK ONE 0 CITY.!ll TOWN 0 VILLAGE
~~~CIFY Rn~A Hill
D. STREET ADDRESS 111 South Hall ZIP 28458
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 27 3B. DATE OF BIRTH MOQ~ / 6; /~
4. EMPLOYMENT
A. USUAL OCCUPATION T e(;lr.hAr
B. TYPE OF INDUSTRY OR BUSINESS FrJlJr.ation
5. PLACE OF BIRTH ~rAen~hnrn NC
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME StP\lpn I AA HnwArtnn
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A MAIDEN NAME Caroline naphne Cuthbertson
B. COUNTRY OF BIRTH LJ S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE 1-1 olMe rto n
(OPTIONAL. SEE REVERSE)'
D. SOCIAL SECURITY NUMBER 1 ? 1-66-6R3 7
12 RESIDENCE A.NCiSTATE) B. DI(mJ~~)
C. CHECK ONE 0 CITY eI TOWN 0 VilLAGE
~~~CIFY Rose Hill
D STREET ADDRESS 111 South Hall
ZIP 28458
o YES~ NO
/f'Q8?
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
O~ /-\ 6
M NTH DAY
13. A. AGE 26
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION T e::lr.hAr
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH Bronx, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME .1::lmA~ Mr. r.::lffrey
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Anne Cornelia Melnicki
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
DEATH
n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
C. DATE LAST MARRIAGE ENDED?
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
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
w
en
z
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o
::i
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly sweiir/affirm, depose and say, that to the besl1t of my knowledge and belief that the information I provided is true
as to my right to enter Into the %'J-f!iJ1...e state . I .~
21. SIGNATURE OF GROOM~ (fl/lM,f),l-'^l;;:;;:' A~ 22. SIGNATURE OF BRIDE~
~s C RR NTNAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BE REL, J A --vi I .n A, ;....
SIGNATURE OF TOWN OR CITY CLERK ~ __~ --I---IL1 (L!!.-L.L.!.
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~ 11 to pertorm 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.
,,-I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C
TIME MONTH YEAR
SEAL SIGNATURE ~
MAILING ADDRESS
'-r-I 20 Middleb
STREET
I CERTIFY THAT I SOLEMNIZEO
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
o
o
o
by New York Domestic
MONTH
YEAR
07
16
2008
09
13 2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~TC.HcJ
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
H APP,~" c..
,J
NAME (PRINT)
SIGNATURE~