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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Anthn~D,&,~ynp. nnR,~~W~u~~E
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c~ 1368 '
~~~:J~R 1 01
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 109 72 3075 '
D. SOCIAL SECURITY NUMBER _ __ - __ - ____
2. RESIDENCE A. NY B. nlltr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE ..tJ CITY D TOWN D VILLAGE
~~~CIFY BeFlcon
D. STREET ADDRESS 48 C Hudson View Drive ZII' 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tl YES D NO
3. A. AGE~O 3B.DATEOFBiRTH Of! /14 /1977
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION WFlrehou~e Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Fresenius Med. Care
5. PLACE OF BIRTH Riaewood. New Jersey
(C~ STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Wayne Dobkowski
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Elaine Longo
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MAR81AGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEA'fl1
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) (CITYICOUNTY, STATElCOUNTRY.IF NOT USA) SELF SPOUSE
I
STATE RL.E NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
KFlren Del Valle
MIDOLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAlDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE nnhknw~ki
(OPTIONAL - SEE REVERSE)065 72 1197
D. SOCIAL SECURITY NUMBER ___ - --
12. RESIDENCEA. NY B. nlltchess
(STATE) (COUNTY)
C. CHECK ONE otJ CITY D TOWN D VILLAGE
AND B
SPECIFY eacon
D. STREET ADDRESS48 C Hudson View Drive ZIP 12508
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? ~ YES D NO
~5 A"981
DAY YEAR
13. A. AGE ?6
06
MONTH
3B. DATE OF BIRTH
14. EMPLOYMENT
A.' USUAL. OCCUPATION Hair Stylist
B. TYPE OF INDUSTRY OR BUSINESS Marlene Weber
15. PLACE OF BIRTH Bronx, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Joseph Del Valle
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Rita Anne Goldstein
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIA6ES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(3) D ANNULMENT (2) D DEATH
/ /
-. ',- YEAR
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o 1ST
D 2ND
D 3RD
D 4TH
belief that the Information I provided Is ru a
D
D
D
ATE 08/28/2007
ngers Falls, NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o D RELIGIOUS ~ CIVIL
9 D OTHER, SPECIFY
w
en
z
w
(.)
::;
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say
as to my right to enter Into the ma
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFO
SIGNATURE OF TOWN OR CITY CLERK ~
This llcensa authorizes the marriage in New York State of the
Relations Law ~11 to perform marriage ceremonies within New York Sta
D If checked, this license Is to be used onl
24. TOWN OR CITY CLERK
J
29. OFFICIANT
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
E OF BRIDE ~
DATE
by New York Domestic
YEAR
10 27 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 7)(.J7'C.,.JrSS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
DCITY
ie..
SPECIFY
NAME (PRINT)
SIGNATURE~