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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Da"i6tDQordon At~~!M){,URNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYrrowN Wappinger
~~~~c: 13fi8 .
~G~~~~R 85
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
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B. BIRTH NAME, IF DIFFERENT
11. A. FULLNAME FIRST Rp.oM~~ Ro~p. SfliJ~ENTSURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT GrOSSma'l
C. SURNAME AFTER MARRIAGE Atherlp.y
(OPTIONAL - SEE REVERSE)'
D. SOCIAL SECURITY NUMBER 058-62-7379
12. RESIDENCE A. NY B. nlltr.hp.!=:!=:
(STATE) (COUNTY)
C. CHECK ONE oiZI CITY 0 TOWN 0 VILLAGE
~~~CIFY BeF.lcnn
D. STREET ADDRESS 11 C Van Horn Circle ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE .15 3B. DATE OF BIRTH n? A 7 ;(qfi?
MONTH DAY YEAR
+
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 n~-58-753~
2. RESIDENCE A. NYsTATE) B. q~ess
C. CHECK ONE .zJ CITY 0 TOWN 0 VILLAGE
~~~CIFY Rp.F.lcnn
D. STREET ADDRESS 11 C Van Horn Circle ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
nR / 11 /1 Q60
MOI'lTR DAY YEX"R
3. A. AGE 47
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION r.F.lrrp.ntp.r
B. TYPE OF INDUSTRY OR BUSINESS DEB Carpentry
5. PLACE OF BIRTH North Tarrvtown, New York
(CITY, STATE I COumRY IF NOT USA)
6. FATHER
A. NAME Kp.nnp.th r,orrlon Athp.rlp.y
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Virginia Ann McKee
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
17. MOTHER
A. MAIDEN NAME Elizabeth Anne Cran
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / 12 / 2004
MONTH DAY, . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? t!f YES 0 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
01/12/2004 Manhattan, NY r:1
14. EMPLOYMENT
A. USUAL OCCUPATION Secrp.tary
B. TYPE OF INDUSTRY OR BUSINESS Royco Auto Parts
15. PLACE OF BIRTH Queens. New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Rohert Andrew Grossman
'B. COUNTRY OF BIRTHU SA
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
100
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 11 / 15 / 1999
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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 11/15/1999 Pouahkeeosie. Nv 0 ~ 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the marnage state.
21. SIGNATURE OF GROOM. 22. SIGN URE OF BRIDE.
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DEATH
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DATE
08/08/2007
bride and groom named above by any person authorized
e. THIS LICENSE VALID IN NEW YORK STATE ONLY.
Iy for the purpose of a second or subsequent ceremony.
25. A. SOLlEMNIZATION PERIOD BEGINS
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
YEAR
MONTH
DAY
YEAR
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 08/08/2007
ppinger Falls, NY 12590
CITYrroWN STATE ZIP
, 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 0 RELIGIOUS
IIt{o~ Oq 15.)00 900THER,SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY &~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF EJ TOWN OF ~LAGE OF
SPECIFY /ld~./LLt..,
09:53 AM 08
PM
09
2007
10
07 2007
1 5YCIVIL
29. OFFICIANT -C H Lt ~ " .. -rl
NAME (PRINT) \ ,nc;; ,.., IJ .v
SIGNATURE~' 1./;.."",_ . YY~A ~Al if')
MAILING ADDRESS
/1 J<I...u;tJ) ~ f(rtJ. C '"1l-<h.h7fL/~./,
STREET ITYITOWN .
SO. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
DoH-98 (03f2006)