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COUNTY Dutchess
C1TYfTOWN Wappinger
~~~:~c: 1368 '
~~~:J~R 2
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Arthur William Horton
MIDDLE CURRENT SURNAME
I""
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
FROM THE BRIDE
Kathleen M. Bianco
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT L ynt
c. SURNAME AFTER MARRIAGE Horton
(OPTIONAL - SEE REVERSE) 087-50-4986
D. SOCIAL SECURITY NUMBER
12, RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY D'" TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 34 Tor Rd. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
13. A. AGE 50 3B. DATE OF BIRTH 08 / 04 /1956
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Licensed Dental Assistant
B. TYPE OF INDUSTRY OR BUSINESS Dental
15. PLACE OF BIRTH Peekskill, New York
(CITY, STATE I COUNTRY IF NOT USA)
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York
(STATE)
C, CHECK ONE 0 CITY [!" TOWN 0
~~~CIFY Waooinaer
D. STREET ADDRESS 34 Tor Rd.
115-48-0075
B. Dutchess
(COUNTY)
VILLAGE
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES cI NO
12 / 30 / 195
MONTH DAY YEAR
3. A. AGE 5?
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Ketaii
5. PLACE OF BIRTH Pouahkeeosie. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert L vnt
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Edwina Desmarais
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 3
6. FATHER
A. NAME Lynn Alexander Horton
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Bernice L. Sutton
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3) O~VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09/ 10 / 1996
MONTH J 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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
08/15/1986 Westchester County, NY 0 Dol
09/10/1996 Dutchess County, f'JY Dol 0
o 0
o 0
al~t exists
~,
9. ~~~~~~lRM6'tWh~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) O~IVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? OV 22 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (crryICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 07/22/2003 Sandoval County. NM Dol 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swe!lr/affirm, dep.ose and say, that to the b~Of ~wledge and belief that the information I provided is ,t e
as to my nght to enter Into the~ta~ II ~ " /
21. SIGNATURE OF GROOM ~ \ 22. SIGNATURE OF BRIDE ~
USEC ~E ~l
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME ' ~
SIGNATURE OF TOWN OR CITY CLERK ~ . ~
This license authorizes the marriage in New' Y, State of the bride and groom named above by any person authorized
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 only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
n C. Masterson
C.
DEATH
o
(2) 0 DEATH
2003 .
YEAR
nd that I deClar\that n\
~~ Y'N..,
USE CURRENT N~
DATE
01/19/2007
by New York Domestic
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-v-I MAILI~cet~rdS
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
TIME
MONTH
AM
02:4PM
01
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY]),.d::cl.;<;,s
C. LOCATION OF CEREMONY
(CHECK ONE AN SPECIFY)
o CITY OF
29. OFFICIANT
NAME (PRINT)
o VILLAGE OF
L
SPECIFY
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
SIGNATURE~