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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Waage
(OPTIONAL - SEE REVERSE)122 70-7033
D. SOCIAL SECURITY NUMBER -
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY of'J TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESs606 Chelsea Cay
COUNTY Dlltchess
CITYfTOWN Wappinger
~~~:~c;1 ~nR
~~~I~~~R21
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ray~~un P:=IIII WC~~~SURNAME
1. A. FULL NAME
11. A FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 0!11- 7 4-RR4!1
2. RESIDENCE A. N'(STATE) B. r:Mt~,qt~~
c. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \^t .
SPECIFY "applnopr
D. STREET ADDRESS nOn Chelsea Cay ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
M~ / g? / ~JlR81
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
MM~~~ann Reill~URRENT SURNAME
-.J
FIRST
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGI;?
13. A. AGE ?? 3B. DATE OF BIRTH 08 ~1
MONTH OA Y
ZIP 12590
DYES '6 NO
/1'985
YEAR
3. A. AGE 27
4. EMPLOYMENT
A. USUAL OCCUPATION Dri\ler
B. TYPE OF INDUSTRY OR BUSINESS Fprl F)( Frp.i(Jht
5. PLACE OF BIRTH Nf?yrth T arr~to'^''' Npw Y nrk
(CI ,STATE I COU TRY IF NOt USA)
6. FATHER
14. EMPLOYMENT
A. USUAL OCCUPATION Day Care Provider
B. TYPE OF INDUSTRY OR BUSINESS Dav Care
15. PLACE OF BIRTH City Of Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
A. NAME Ed'.'I!ard Ralph \}\/aage
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Mary Grace Casad onE'
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MAR81AGE ?
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE' .eIVIL 'ANNUI:MENT
16. FATHER
A. NAME .John Peter Reilly
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Arlene May Arcabascio
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
1
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) !ii!l'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03/ 15 / ?n04 c
MONTH DA Y mil
D. ARE ANY FORMER SPOUSE(S) ALIVE? [})'YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o ~ 1ST 0 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
sta . ,
~~U~
DATE 03/25/2008
03/15/200-1 PDblghk~~pii~, New York
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the marn
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
21. SIGNATURE OF GROOM~
~
{ SEAL }
'-v-I
NAME (PRINT)
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 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
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE~
DOH-96 (0312006)
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
1 0:44AM
PM
03
26
2008
05
24 2008
10 CIVIL
26. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUm-V --L,~dr~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~ TOWN OF 0 VILLAGE OF
SPECIFY ~ i (;'s.!-' l:O