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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~1368 .
~~~I~J~R 131
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
pp.t16&L~lnhn K :=lr<J~~~NT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
nA~t~~KfnnA T a'1~~~NT SURNAME
~
11. A. FULL NAME
FIRST
1. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~:=lrnvir.
(OPTIONAL - SEE REVERSEb
D. SOCIAL SECURITY NUMBER 54-74-1108
12. RESIDENCE A.N Y B.nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY otl TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDREss4142 Route 52
ZIP 12531
o YESotJ NO
%979
YEAR
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 095-70-5095
2. RESIDENCE A. N Y B. [1lltr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
~~~CIFY F:=l~t Fi~hkill
D. STREET ADDRESS 4142 Route 52 ZIP 12531
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..a NO
3. A. AGE36 3B. DATE OF BIRTH MJZ / ~J / ~filO
4. EMPLOYMENT
A. USUAL OCCUPATION T Ar.hnid:=ln
B. TYPE OF INDUSTRY OR BUSINESS Fire Systems. Inc.
5. PLACE OF BIRTHValhalla, New York
(CITY. STATE I COUNTRY IF NOT USA)
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE?R 3B. DATE OF BIRTH 05 J.1(1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Home Depot
15. PLACE OF BIRTHMt. Kisco. New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Ross Warren Tanner
'B. COUNTRY OF BIRTJ.! S A
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6. FATHER
A. NAME PAtAr Karnvir.
B. COUNTRY OF BIRTH Czechoslovakia
7. MOTHER
A. MAIDEN NAME Jana Zaleska
B. COUNTRY OF BIRTH Czechoslovakia
8. NUMBER OF THIS MARRIAGE 3
17. MOTHER
A. MAIDEN NAME Estelle L. Lemieux
B. COUNTRY OF BIRTJ.! S 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
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
.DIVORCE _____.__-GfVIL-ANNLJ~EIfF-
2 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGEENDED? 01 / 03 / 2005
MONTH DAY YEAR
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
1ST 09/13/2000 White Plains. N Y 0 ~ 1ST
2ND 01/03/2005 pOUQhkeepsie, N Y ~ 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose a my knowledge and belief that the information I provided is true
as to my right to enter into th
21. SIGNATURE OF GROOM.
o 0
o 0
o 0
o 0
o legal impediment exists
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. '.~ YEAR
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
USE CUR ENT
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of
Relations Law ~11 to perform marriage ceremonies within New York
o If checked, this license is to be used
~ 24. TOWN OR CITY CLERK
} NAME (PRINT) J C Masterson
{SEAL SIGNATURE ~
'-v-' M~~1OOgn
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE
e bride and groom named above by any person authorized by New York Domestic
te. THIS LICENSE VALID IN NEW YORK STATE ONLY.
nly for the purpose of a second or subsequent ceremony,
25. A. SOLEMNIZATION PERIOD BEGINS
YEAR MONTH
YEAR
TIME
MONTH
01 :03 ~~ 10
03 2007 12 01 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY pJfiJ ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY lo(,..~ SPtI. i ~
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
SIGNATURE~