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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368 '
~~~I~~R 35
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Herve Yves Marie Kermel
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lori Ann Maiorino
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
..
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 120 88 2445
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New Yark B. Dutchess
(STATE) (COUNlY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
~~~CIFY Waopinger
D. STREET ADDRESS 40 Edgehill Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tJ NO
3. A. AGE 33 3B. DATE OF BiRTH 11 / 15 / 1973
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kermel
(OPTIONAL - SEE REVERSE) 116-66-3983
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY f'!1 TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 40 Edgehill Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 31 3B. DATE OF BIRTH 10 /23 ",1975
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS IBM
5. PLACE OF BIRTH Lannion. France
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Bernard Kermel
B. COUNTRY OF BIRTH France
7. MOTHER
A. MAIDEN NAME Yvonne Marie Noeline Le Gourrierec
B. COUNTRY OF BIRTH France
8. NUMBER OF THIS MARF,lIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS IBM
15. PLACE OF BIRTH Islip, New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert C. Maiorino
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Janice L. Artura
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
9. ~~~~~d'e"RM6'FR~~~gus MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (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? 02/ 18 / 2000 c. DATE LAST MARRIAGE ENDED? / /
MONT!1,..o DAY YEAR MONTH DAY. -, ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [J'YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMlATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE -. PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 02/18/2000 Effingham County, Illinois 0 ~ 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, 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 right to enter into the mamf~e state. ~ . .
21. SIGNATURE OF GROOM ~ ~ ~ 7 22. SIGNATURE OF BRIDE ~ ~ a."......... '?Yl~
USE cu USE CURRENT NAME
23. suasCRIBED AND SWORN TO/AFFIRMED BEFORE ME 05/09/2007
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New 'Yo State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license Is to be used onl for the urpose of a second or subsequent ceremon .
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J C. Ma terson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~: DATE 05/09/2007
'-v-I MAI~~rtHr8ffis sh Rd, Wappinger Falls, NY 12590 06:22~~ 05 10 2007 07 08 2007
STREET ClTYrrOWN STATE ZIP
~~~R~~RT':~ 10~0~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. Y YEAR 0 n RELIGIOUS
DATE AND AT THE TIME AND xx
PLACE INDICATED. 5 /26 /20 0 7 9 0 OTHER, SPECIFY
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL MlNULMENT
o 0
DEATH
o
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNnSuffolk
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~~,Jlf~~~Rev _ Francis Vattakudi viI
SIGNATURE~ ~ &-...--~ \ bit;;. =k~
MAILING ADDRESS ,
STIi~ Cl!uJ. d! S L. t:rr~~g5' Park, NY
30. WITNESS TO CEREMONY
RC' pr;p~t
.5-;& -~ 7
TITLE
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY Kings Park
DATE
11st~~
ZIP
31. WITNESS TO CEREMONY
:r vv-;CJ tJ
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
SIGNATURE~
cn~
ore.-
NAME (PRINT)