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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~c~1368 .
~~~I;;~R146
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
!;?[j~n I Trovi~URRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
'I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.JAnnifAr r. RogArs
MIDDLE CURRENT SURNAME
.-l
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER OQ 1- 7? -:o~?
2. RESIDENCE A. NXSTATEI B. qMt&./:))ess
C CHECK ONE 0 CITY 0 TOWN,JJ VILLAGE
~~~CIFY Worrin!)prc:: F~IIc::
D. STREET ADDRESS 1 ~ North RAmsAn A VAn! IA ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? otJ YES 0 NO
3. A. AGE23 38. DATE OF BIRTH M~~ / Jl / JE~J34
4. EMPLOYMENT
A. USUAL OCCUPATION Supen/isor
B. TYPE OF INDUSTRY OR BUSINESS Rpt~il
5. PLACEOFBIRTHr.itv Of PnllnhkpA.pc::ip, Npw Vnrk
(CI~ STATE / COUNmy IF NOT USA)
6. FATHER
A. NAME Gerald F Travis
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A.MAIDEN NAME r.onst~nr:A Alv~rA7
8. 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
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Travis
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 073-70-3693
12. RESIDENCE ANY B.nlltr.hPSS
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ~rrlnOAr
D. STREET ADDRESS'ZB Carnaby Street
13. A. AGE24
3B. DATE OF BIRTH
ZIP12590
o YES~ NO
/'f'qR1
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
n~ /'1'1
M NTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION M~n~OAr
B. TYPE OF INDUSTRY OR BUSINESS Retail
15. PLACE OF BIRTHNorth T~rrvtown, New York
(CITY, STATE / COi:i!ITRY IF NOT USA)
16. FATHER
A. NAMEE'~I II Inc::prh ROOArc::
'8. COUNTRY OF BIRT"'-l S A
17. MOTHER
A MAIDEN NAME Maria Christine Anzovino
B. COUNTRY OF BIRT"'-l S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
o
DEATH
n
DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END?
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, STATE/COUNTRY, 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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the information I provided i
o
o
o
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFO
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
DATE 12/11/2007
by New York Domestic
,-A-..
{ SEAL }
"-v-I
TIME
MONTH
YEAR
MONTH YEAR
10:51 AM 12
PM
2007
02 09 2008
12
o 0 RELIGIOUS 1 ~ CIVIL
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY.2>v n::..J.HE9_P
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY /?;VG-ffK:JE€PSI t=.
TITLEr~6t[!,ii.uIJ:r;n".~ -#2.
T(
SIGNATURE