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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Feiw::Irei Willi::lm CI::Irk
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368
~~~I;~~R 15
1 . A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 119-54-6375'
2 RESIDENCE A. NY B. nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN~ VILLAGE
~~~CIFY W::Ippingers F::IlIs
D STREET ADDRESS 2791 West Main 8t: Apt 6 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? !'l YES 0 NO
3. A AGE 34 3B. DATE OF BIRTH OQ / 11 / 1 q71
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION H\lAr. Tpr.h
B. TYPE OF INDUSTRY OR BUSINESS HV AC
5. PLACE OF BIRTH Nnrth T::Irrvtnwnl Nv
(CITY. STATE / COUmRY IF NOT USA)
6. FATHER
A NAME William H Clarl<
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A MAIDEN NAME M::Iry M::Irg::lrAt Kelly
B. COUNTRY OF BIRTH t , S A
8. NUMBER OF THIS MARI3IAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
(2) 0 DEATH
o
o
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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Antoinette Josephine Molinari
FIRST MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE C 1::1 rk
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 069-72-8031
12. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDREss2791 West Main 8t; Apt 6 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
09 . /10 /1'975
MONTH DAY YEAR
13. A. AGE 1?
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Cosmetologist
B. TYPE OF INDUSTRY OR BUSINESS Cosmetology
15. PLACE OF BIRTH Bronx New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME R::Ilph .11 leiA Molin::lri
'B. COUNTRY OF BIRTH U 8 A
17. MOTHER
A. MAIDEN NAME Barbara Ann Rella
B. COUNTRY OF BIRTH U 8 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
~
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 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is tru
as to my right to enter into the ~rnage state.
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF B
o 0
o 0
o 0
o 0
ediment exists
.t
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE
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
~
{ SEAL }
~
by New York Domestic
TIME
MONTH
NAME (PRINT)
YEAR
MONTH
YEAR
1 0:52AM
PM
12
2008
05
1 0 2008
03
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM
PM
TATE
27. TYPE OF CEREMONY
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)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30. WITNESS TO CEREMONY
CITYfTOWN
NAME (PRINT)
SIGNATURE~
DOH.98 (03/2006)
2B. PLACE WHERE MARRIAGE OCCURRED
,
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~