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COUNTY Dutchess
CITYfTOWN VVappinger
DISTRICT
~~~~~R1368
NUMBER 7 ~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ja~Q.ponald 8Q~T SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
COl.lrt';'D~~ Jo Pasq~~T SURNAME
~
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 c:: 0 kg I
(OPTIONAL - SEE REVERSE'j
D SOCIAL SECURITY NUMBER 060-70-93RO
12 RESIDENCE ANY (STATE) B.D~SS
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND D b" .
SPECIFYrOllg ~E'E'p~lE'
D STREETADDRES~n I inr.nln AWmllp. A-? z1P1?601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..tJ NO
13 A. AGE2~ 3B. DATE OF BIRTH QJNTH,,() ~AY -1 ~g~
14. EMPLOYMENT
A. USUAL OCCUPATION Sale, Associate
B. TYPE OF INDUSTRY OR BUSJNESS Rpt~i1
15. PLACE OF BIRTHMt I<iscn NY
(CITY, STATE / C6UNTRY IF NOT USA)
16. FATHER
.A. NAME Robert Pasquale
B. COUNTRY OF BIRTf-i I ~ A
17. MOTHER
A. MAIDEN NAME l(;lne H~lInr~n
B. COUNTRY OF BIRTf-i I S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 087 82 QO 1 ~
2 RESIDENCE A. N'(STATE) B q~tOOpsc
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND
SPECIFY \/'lappinger
D. STREET ADDRESS 115 Cider Mill Loop ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES.,[J NO
McOa / ao / ~~8
3. A. AGE 20
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Foward Observer
B. TYPE OF INDUSTRY OR BUSINESS United <3tliltes Army
5 PLACE OF BIRTH ~\flJ~h~/~5Wji~'N~JsA)
6. FATHER
A. NAME Jooeph J. 801<01
B. COUNTRY OF BIRTH U <3 A
7. MOTHER
A. MAIDEN NAME Anna M. Targuini
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
o
o
o
o
o
(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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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
o 0
o 0
o 0
o 0
I impediment exists
1ST
2ND
3RD
1ST 0
2ND 0
3RD 0
4TH 0
I duly swear/affirm, depose and say that to the best of my knowle ge
as to my right to enter into the m ge state.
21. SIGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN FIRMED BEFORE
SIGNATURE OF TOWN 0 CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 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
by New York Domestic
~
{ SEAL }
'-v-'
NAME (PRINT)
TIME
MONTH YEAR
DATE
12 22 2008
WN
I
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR 0 0 RELIGIOUS
12: 07 A~ 07 01 08 90 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1 00 CIVIL
A. STATE NEW YORK B. COUNTY DUTCHEa a
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ex TOWN OF 0 VILLAGE OF
SPECIFY POUGHKEEPSIE
~~~tj~~~~T Susan J. Miller
SIGNATURE ~ \ ~11f) ()./\f\ ~' m A Q QJ..r'\,
MAILING ADDRESS- ~ - .
1 Overocker Road oughkeepsie
STREET CITYfTOWN
Marriage Officer
TITLE
DATE
July 01, 2008
12603
New York
STATE
ZIP
31. WITNESS ~EMONY
NAME (PRINT) ~
SIGNATURE~ 'A'./(
~'?A
30 WITNESS TO CEREM,9N~ \ D~'~1J~
NAME (PRINT) (\\ '--~ jJ~ _ ~_h-_
SIGNATURE~ ~I/~\j -:tl~