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COUNTYDlltchASS
CITYfTOWN Wappinger
~~~~:1308 .
~5~I~J~R148
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Franqj~John BOZ~PlJrSURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Coy/iM;1ey L '^'eb~~RENT SURNAME
..J
1 . A. FUll. NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. s~S~~~~rc-~~~t~~C~~iOZliiik
D. SOCIAL SECURITY NUMBER !1!17 -0 1-!187!1
12. RESIDENCE ANY(STATE) B.~~SS
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY appmOFlr
D. STREETADDRESs13 Alpine DrivA, Apt G zIP12590
E.IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESIl(] NO
~~NTH -1 ~AY ,{~gg
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 111-72-8905
2. RESIDENCE A. NXSTATE) B. q~~ellll
C. CHECK ONE 0 CITY..,l] TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 13 AlpinFl nriw=!. Apt G ZIP 1 ?!19Cl
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'lItJ NO
3. A. AGE27 3B. DATE OF BIRTH M~ / ~l / ~Jj130
4. EMPLOYMENT
A. USUAL OCCUPATION t:.uto Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Alltn RAp~ir
5. PLACE OF BIRTH<fc~~ST~P~~.N,~OT USA)
6. FATHER
A. NAME Francii John BOZiik
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Deborah Mary Campbell
B. COUNTRY OF BIRTH I 1St:.
8. NUMBER OF THIS MAR81AGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE -CIVIL ANNULMENT
DEATH
n
13. A. AGE'l7
14. EMPLOYMENT
A. USUAL OCCUPATIONDome,;tir. FnginAAr
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTHYrAka r.alifnrnia
(CITY. STATE I COUNTRY IF NOT USA),'
3B. DATE OF BIRTH
16. FATHER
A. NAMELouis loseph Weber Ir
. B. COUNTRY OF BIRTt-!. J ~ A
17. MOTHER
A. MAIDEN NAMEnari AnnA PAtAr~An
B. COUNTRY OF BIRTt-Il ~ A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
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
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swe!!r/affirm, dep'0S8 and say, that to the best of my knowledge and belief that the information I provided is true and that I decllilLe that no legal impediment exists
as to my nght to enter Into the lage tate /J - n-----.."
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~(_J m .I' J-.n /)//1 lJ.)r2{1J'-,
.. ~NTNAME
23. ~::~c,.~~~DO~~~~OJ': ci~AmRR~E~ BEFORE DATE 12/28/2007
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New Yorl< Domestic
Relations Law ~11 to perform marriage ceremonies within New Yorl< 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 ceremon .
,-I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME(PRINT) .ln~M~
{SEAL SIGNATURE ~ . DATE 1 ?/?R/?on7 TIME MONTH YEAR MONTH DAY
MAILING ADDRESS AM
'-v-' STfe~ Middlebllsh Rd, Wap~~~~s Falls, S~A~ 12590ZlP 01:46 PM 12 29 2007 02 26 2008
~~~R~~RTr~J IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND · 0
PLACE INDICATED. . :. PM 9 0 OTHER, SPECIFY
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
YEAR
IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. CO~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ,/
o CITY OF 0 TOWN OF ~LLAGE OF~ It
CIFY W~(J,~..ti\.&.lIK5
SIGNATURE~