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COUNTY Dutchess
CITY/TOWN Wappinger
~~~:~CRT 1368
~~~~~~R 23
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.1::Isnn I eonard DiMase
MIDDLE CURRENT SURNAME
I
STATE FIL.E NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cynthia Wasilewski
MIDDLE CURRENT SURNAME
-.J
1. A. FUll NAME
11. A. FULL NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE DiMase
(OPTIONAL - SEE REVERSE) 9
D. SOCIAL SECURITY NUMBER 150- 7 4-6 44
12. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY!ii"l TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 5 Pve Lane
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 054-74-6200'
2. RESIDENCE A. NY B. nlltr.hASS
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY ReAkman
D. STREET ADDRESS 29 High Ridge Road ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
08 /? 1 / 1 QRn
MONTH DAY YEAR
ZIP 12590
DYES1!"lNO
/1'983
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AGE ?~ 3B. DATE OF BIRTH 01' /04
MONTH DAY
3. A. AGE 27
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION IT An~ly!=:t
B. TYPE OF INDUSTRY OR BUSINESS Pepsi
5. PLACE OF BIRTH NAW Rnchele, New York
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPL.OYMENT
A. USUAL OCCUPATION Assistant Manager
B. TYPE OF INDUSTRY OR BUSINESS Retail
15. PLACE OF BIRTH Livingston. New Jersey
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
16. FATHER
A. NAME Teddy Wasilewski
'B. COUNTRY OF BIRTHPoland
17. MOTHER
A. MAIDEN NAME Sophie Lubis
B. COUNTRY OF BIRTH Poland
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
~
:;:
<C
C
A. NAME Leomlrd Anthnny ni I\II~!=:P
B. COUNTRY OF BIRTH L J S A
7. MOTHER
A. MAIDEN NAME I ::Illr::l AnnA I ::I Porta
B. COUNTRY OF BIRTH I J S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say,
as to my nght to enter into the mar
21. SIGNATURE OF GROOM~
o 1ST 0 0
o 2ND D 0
o ~D 0 0
o 4TH 0 0
belief that the information I provlded~'s e and that I declare that no legal impediment eXists
) 2 . SIGNATURE OF BRIDE lj=~Y"R d j.1 a. '/) ~ 1 0 Q.,(0L...'
( k1 J ~ USE CmtRENT NAME
~ '--t' ItCLI~ DATE 03/?7/?008
W
(/)
Z
W
o
::i
23. SUBSCRIBED AND SWO AFFIRMED BEFOR
SIGNATURE OF TOW 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 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CL.ERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
MONTH
YEAR
by New York Domestic
,-I'-...
{ SEAL }
'-..-I
TIME
MONTH
YEAR
08:47AM
PM
2008
05
26 2008
03
28
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
I
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
'I: 00: '-I if 03
TATE
27. TYPE OF CEREMONY
o Xl' RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYD( lo.. t~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF r;( TOWN OF 0 VILLAGE OF
SPECIFY &..., T ~;,hki \ l
10 CIVIL
29. OFFICIANT ~ ViA.s c-~ \ \ C. \ .
NAME (PRINT) V gr. ~~""""l.O~ '-' ... 1I),~\c:...c...o
SIGNATURE ~ ~. M M.~-l~J \!fl ~.- ,
MAILING ADORE S ()
1',0. ~x: 4.i.8' -+b~~\.\ 06. n 4
STREET d'ITY /TOWN ,
30. WITNESS TO CEREMONY
NAME (PRINT) J
TITLE ~ ~c;;. ~lC1ies-t
DATE-ftrxll\ Y/ ;too &'
i~3
STATE
NAME (PRINT)
SIGNATURE