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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~~ 1368
~~~I:~~R 17
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
1. A. FUll NAME
Kenneth .1::Jme~ Orefice
MIDDLE CURRENT SURNAME
FROM THE BRIDE
Nicole Michele Adair
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Nicole Michele Kim Adair
C SURNAME AFTER MARRIAGE Orefice
(OPTIONAL - SEE REVERSE)173 66 9223
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEA.New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeeosie
D. STREET ADDRESS 9 Donna Drive
11. A. FUll NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 100-72-7044'
2. RESIDENCE A. NY B. nlltr.he~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN~ VILLAGE
~~~CIFY W::Jppinger~ Falls
o STREET ADDRESS 10 Delavergne Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tl YES 0 NO
nQ / 06 /1 QR7
Mo*li DAY YEAR
ZIP 12603
DYES tj NO
/1'985
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?? 3B. DATE OF BIRTH 12' /'12
MONTH DAY
3. A. AGE 20
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION SE>lf fmr1nyerl
B. TYPE OF INDUSTRY OR BUSINESS landscaping
5. PLACE OF BIRTH Pnllnhkeen!=:ie, New Yark
(CITY, ~ATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME James E Orefice
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME r.::Jrnl-::Jnn M::Jrtin
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATION Assistant
B. TYPE OF INDUSTRY OR BUSINESS Day Care
15. PLACE OF BIRTH Philadelphia. PA
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME .John .James Adair Jr
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lois Ann Schiller
B. COUNTRY OF BIRTHU SA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
_DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIYIL ANNULMENT
o
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
YEAR
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
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10.IF-PREVIOUSLYDIVORCED 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
21. SIGNATURE OF GROOM~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
wledge and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ --1.]. \ U\.i 1f\ 11 ~ iA
USE CURRENT~~
DATE 03/12/2008
by New York Domestic
w
en
z
w
o
::::i
U
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York ate of the bride and groom named above by any person authorized
Relations Law ~11 to perfonn 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
~
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
YEAR
TIME
MONTH
YEAR
AM
05:59PM
2008
05
11 2008
03
13
TATE
27. TY~ OF CEREMONY
o e("RELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY {)lC'O.tU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF l'iil: TOWN OF 0 VILLAGE OF
SPECIFY ~ w \ l) t ~~R...
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