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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tim~t~L~ S Tem~~R~!mLRNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368 .
~~~~;~R 35
1. A. FULL NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
Lo
.-J
11. A. FULL NAME
SUPPLEMENTAL FILE
FROM THE BRIDE
Nanc~ Ann Burkard
MID LE CURRENT SURNAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 116 62 9223
D. SOCIAL SECURITY NUMBER _ _ _ - __ - ____
2. RESIDENCE A. NY B. nutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN otJ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 11 S. Gilmore Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? r!'f YES 0 NO
3. A. AGE 38 3B. DATE OF BIRTH nR /?~ / 1 ~n~
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE T empestilli
(OPTIONAL - SEE REVERSE) 093 64 6590
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN l'!l'l' VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 11 S, Gilmore Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? r!1 YES 0 NO
/14 /1976
DAY YEAR
ORE ~E ~
...;
This license authorizes the marriage in New 'v,.. _. ..._ _,,__ _. ~ 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
NAME (PRINT)
4. EMPLOYMENT
A. USUAL OCCUPATION r.~rpenter
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Daytona Beach, FL
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME I ~wrAnce r. Tempe~tilli
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Grace Casamassima
B. COUNTRY OF BIRTH Italy
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH EN DE
DIVORCE CIVIL ANNULMH
1 n
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (:
C. DATE LAST MARRIAGE ENDED? n1/
MONTH
D. ARE ANY FORMER SPOUSE(S) ALIVE? r:Yr-ES
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE
DATE OF DECREE PLACE ISSUED
(MONTH, DAY. YEAR) (CITY/COUNTY. STATE/COUNTR'
n1/14/?nnR Poughkeepsie N'
1ST
2ND
3RD
4TH
I duly swear/affirm, dej:lose and S
as to my right to enter into the
21. SIGNATURE OF GROOM ~
~
{ SEAL }
'-v-I
13. A. AGE 31
08
MONTH
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Hardware
15. PLACE OF BIRTH Manhassat. NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME George R Burkard
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mona D. Hempson
- ~WT"'YOF BJRTH USA
~RIAGE 2
5us MARRIAGES WHICH ENDED BY
CIVIL ANNULMENT
o
IAGE END? (3) [j'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
rAGE ENDED? 06 / 09 / 2003
MONTH DA Y ~ YEAR
I SPOUSE(S) ALIVE? ~ES 0 NO
..
RCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
PLACE ISSUED AGAINST WHOM
I (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I Poughkeepsie, NY 0 cr'
o 0
o 0
o 0
diment exists
DEATH
o
.... ~
RIVERCREST
__...:.,.;........~...:..\JI.=-ll....~
THE WATERFRONT AT FISHKlll-AN AVR COMMUNITY
~~pl(Le/J
- {l€fllt<~ w{
Re a 1f!a IOC; gF
~O()'iJ-
Office 845-831-7000
AVRRivercrest.com
IE~
DATE
by New York Domestic
YEAR
MONTH
YEAR
TIME
MONTH
AM
06:52>M
2008
06
22 2008
04
24
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ITYfT N
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM
PM
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
29. OFFICIANT
NAME (PRINT)
SIGNATURE.
MAILING ADDRESS
STREET
30. WITNESS TO CEREMONY
CITYfTOWN
NAME (PRINT)
SIGNATURE.
DOH-98 (0312006)
28. PLACE WHERE MARRIAGE OCCURRED
TITLE
DATE
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE.