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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~tFl'{.YDRERir:h::mi ~MfN~SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~::f~ 1368 .
~~~I:J~R 1 03
1.' A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 058-70-1005
2. RESIDENCE A. NY B. nlltr:hFl~~
(STATE) (COUNTY)
C. CHECK ONE IlJ CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
D. STREET ADDRESS 1 06 G Prospect Street ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 30 3B. DATE OF BiRTH 11 / 17 / 1 ~76
MONTH DAY YEAR
....
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4. EMPLOYMENT
A. USUAL OCCUPATION C::Irm::ln
B. TYPE OF INDUSTRY OR BUSINESS Metro-North
5. PLACE OF BIRTH Manhattan. Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Franklin Allan Tasch
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Linda Alexis Sisca
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
-DIVORCE-------CIVIL--ANNUI:MENT- ..
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
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/CDUNTY. STATElCOUNTRY,IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
'I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Kell~DM::Irie Sha~~~ENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE T ::I~r:h
(OPTIONAL. SEE REVERSE)074 66 9069
D. SOCIAL SECURITY NUMBER _ - -
12. RESIDENCE ANY B.Dlltchess
(STATE) (COUNTY)
C. CHECK ONE III CITY 0 TOWN 0 VILLAGE
~~CIFY Beacon
D. STREET ADDRESS 106 G Prospect Street ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
A 4 .:t978
DAY YEAR
13. A. AGE ?~
03
MONTH
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINESS Metro-North
15. PLACE OF BIRTH North Tarrvtown. Nv
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Barry Dean Shapiro
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Suzanne Marie Dailey
B. COUNTRY OF BIRTHU S A
lB. 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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- 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) (CITYICOUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
a:'
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III
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swe!lr/afflrm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my nght to enter Into the marn tate.~ II /1 I 0 . ~ ~
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ ~ I\.'
~URR NTN E
DATE 08/29/2007
by New York Domestic
TIME
MONTH
YEAR MONTH
YEAR
AM 08
05:57 PM
30 2007 10 28 2007
10 CIVIL
2B. PLACE WHERE MARRIAGE Q9'XURRED
UVTc...hc is
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE A~ECIFY)
o CITY OF"'lJ TOWN OF 0 VILLAGE OF
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