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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~CRT 1368
~~~~;~R 30
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Paul Kastanis
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Irene Tsismentzoglou
MIDDLE CURRENT SURNAME
~
1. A. FUU NAME
11. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), iF DIFFERENT
C. SURNAME AFTER MARRiAGE Kastanis
(OPTIONAL. SEE REVERSE) 1 03-78-3459
D. SOCIAL SECURiTY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY 1!1 TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREETADDRESS 57 Nantucket Drive ZIP 12524
E. is RESIDENCE WiTHIN LIMITS OF CITY OR INCORPORATED ViLLAGE? 0 YES ~ NO
/1 0 /1'978
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)092 58 5303
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '!"'J TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 399 Noxon Road ZIP 12603
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
07 / 16 / 1974
MONTH DAY YEAR
3B. DATE OF BIRTH
09
MONTH
13. A. AGE 29
3. A. AGE ::n
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Food Server
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
5. PLACE OF BIRTH Yonkers, New York
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Banker
B TYPE OF INDUSTRY OR BUSINESS Finance
15. PLACE OF BIRTH Queens, New York
(CITY, ST ATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME George Tsismentzoglou
'B COUNTRY OF BIRTH G ree ce
17. MOTHER
A. MAiDEN NAME Stella Costas
B. COUNTRY OF BIRTH Cyprus
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
6. FATHER
A. NAME Ath;:m::!sios K::!stanis
B. COUNTRY OF BIRTH Greece
7. MOTHER
A. MAIDEN NAME Paula Marie Simrany
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
o 0
DEATH
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
B. HOW DID LAST MARRiAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
~
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose ar/p s
as to my right to enter into thai r
21. SIGNATURE OF GROOM~
o
o
o
1ST
2ND
3RD
o
o
o
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22. SIGNATURE OF BRIDE~
23. SUBSCRIBED AND SWORN TO/A IRMED BEFOR
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o " 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
r-^-.
{ SEAL }
'-..,-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
04/1 S/?OOR
AM
03:15PM
04
16
2008
06
14 2008
ZIP
STREET ITY WN
~~~R~~RT~~~ 10~O~~~N~~~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME MO. YEAR o!ii!l RELIGIOUS
DATE AND AT THE TIME AND AM r
PLACE INDICATED. I: eo PM $ / 0 9 0 OTHER, SPECIFY
~';..~t(~~~~T~' iJ I ~.....~> 94'-",:1>-\ "".>m'-' P~I ~'T
SIGNATURE~ _~~ DATE S/ /7/0f::'
MAILING ADDR S I f {PI S. G- ~"" A /\..0 If:! !lJ;k
'-t-V J '_r-rIV.. I/V'''''S'Tr I 2..--603 ZIP
STREET CITYfTOWN <:
30. WITNESS TO 31. WITNESS TO CEREMONY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY b~.-S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY -Pex.> &- ~ IGP~ ~I ~
10 CIVIL
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~
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