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STATE OF NEW YORK I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess DEPARTMENT OF HEALTH
CITY/TOWN Wappinger
DISTRICT 1368 AFFIDAVIT, LICENSE and
NUMBER
REGISTER 45 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FUll. NAME Joseph Richard Demchak 11. A. FUll. NAME Jennifer Theresa Dragonetti
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
Q.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Demchak
(OPTIONAL - SEE REVERSE) 076-64-2316
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY D.....TOWN 0 VILLAGE
AND W .
SPECIFY ap~lnRer
D. STREET ADDRESS 42 Reggie Drive
12590
YES d'" NO
/1980
YEAR
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 092-60-5246
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ot TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 42 Reggie Drive
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 31
3B. DATE OF BIRTH
ZIP 12590
o YES if NO
12/ 19 / 197
DAY YEAR
ZIP
MONTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
01 / 11
MONTH DAY
27
3B. DATE OF BIRTH
13. A. AGE
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION
Unemployed
A. USUAL OCCUPATION Carpenter
B. TYPE OF INDUSTRY OR BUSINESS Carpentry
5. PLACE OF BIRTH Yonkers, New York
(CITY. STATE / COUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Bronxville, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Arthur Dra~onetti
'B. COUNTRY OF BIRTH U A
17. MOTHER
6. FATHER
A. NAME Joseph William Demchak
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Frances Anne Cummings
B. COUNTRY OF BIRTH U S A
1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOR8E CIVIL ANNU6MENT
A, MAIDEN NAME Jacqueline Commisso
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO~CE CIVIL ANN'(fMENT
DEA~
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DNORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
..
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
1ST 0 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 t
as to my right to enter into marnage state,
21. SIGNATURE OF GROOM~ 22. SIGNA RE OF BRIDE~ .
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YEAR
29. OFFICIANT
NAME (PRINT)
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OC~ _.. _.
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF ~LLAGE OF
SIGNATURE ~
MAILING
I
STREET
30. WITNESS TO C
NAME (PRINT) ·
SIGNATURE~ '
bOH-98 (0312006)
O~€~
SIGNAT