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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~: 1368 .
~5~~~~R 144
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John Paul Bertolini
MIDDLE CURRENT SURNAME
I
STATE ALE: NUMseR
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Beverly Joy Jones
MIDDLE CURRENT SURNAME
~
L A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bertolini
(OPTIONAL - SEE REVERSE) 151-68-7466
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE).oJ (COUNTY)
C. CHECK ONE 0 CITY l:J TOWN 0 VilLAGE
~~CIFY Fishkill
D, STREET ADDRESS 15 B Van Cortland Circle ZIP 125U5
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
12 /11 /1975
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 097-72-4150
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 1!1 TOWN 0 VilLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 15B Van Cortland Circle
ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
09 / 02 / 1974
MONTH DAY YEAR
13. A. AGE 30
3. A. AGE 32
3B. DATE OF BIRTH
3B. DATE OF BiRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION ManufacturinQ
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
5. PLACEOFBIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Salvatore John Bertolini
B. COUNTRY OF BIRTH USA
14. EMPLOYMENT
A. USUAL OCCUPATION Operations Manaaer
B. TYPE OF INDUSTRY OR BU~INESS Icon Fun Ing Group
15. PLACE OF BIRTH TeanecK, New Jersey
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Calvin Jones
'B. COUNTRY OF BIRTH USA
7. MOTHER
17. MOTHER
A. MAIDEN NAME Dolores Iannaccone
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~ULMENT
A. MAIDEN NAME Joan Therese Hornung
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,UAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DeeJ'H
DEAOH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATIi
/ /
.,'- YEAR
MONTH DAY
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 AGAINS1; WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF S~OUSE
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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o TI
o 0
o 0
o D
that no legal impediment exists
1ST
2ND
3RD
4TH
I duly swear/affirm, CleP.0S6 and saY1
as to my right to enter into the
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
at to the best 0 my knowledge and belief that the information I provid
estg.
(,/ 22. SIGNATURE OF BRIDE~
W
en
z
W
o
::J
USE CUR
23. SUBSCRIBED AND SWORN TOIAF MED BEFORE ME
SIGNATURE OF TOWN OR CITY Cl RK ~
This license authorizes the marriage in New V. State of th 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 CITYJC RK C M t 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) 0 . as er on
{SEAL} SIGNATURE~
MAI~ teRffd
~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
11
1 0 2006
YEAR
DATE 09/11/200
ails, NY 12590
ZIP
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIM M. DAY YEAR
.~ -AM 0 ~
v: 00 PM 1 .....,0 0 "
STATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF rX TOWN OF 0 VilLAGE OF
SPECIFY f' tT~t :g ~ k k.; l \
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVil
A. STATE NEW YORK B. COUNTYUu.1-<:.b
NAME (PRINT)
SIGNATURE~