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STATE OF NEW YORK I STATE FILE NUMBER I
COUNTY Dutchess (THIS SPACE FOR STATE USE ONL Y)
CITYrrOWN Wappinger DEPARTMENT OF HEALTH
~~~:~~ 1368 AFFIDA VIT, LICENSE and
~G~I~~~R 1 32 CERTIFICATE OF
MARRIAGE L D SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Rodne~ Curtis Cornish 11. A. FULL NAME Dina Ann Simon
FIRST MIDDL CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
"-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Simon - Cornish
(OPTIONAL - SEE REVERSE) 057-64-3729
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY rf TOWN 0 VILLAGE
D. :~:~;AD:E:~~~n~e~hItegate Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [1' NO
08 /04 /f974
DAY YEAR
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 098-68-8001
D. SOCiAl SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!l' TOWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREET ADDRESS 19 D Whitegate Drive
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ri NO
06 / 03 / 1972
MONTH DAY YEAR
13. A. AGE 32
3. A. AGE 34
38. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Driver
B. TYPE OF INDUSTRY OR BUSINESS Royal Carting
5. PLACE OF BIRTH Cooperstown, New York
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BlJSI~fi:SS South Road Auto
15. PLACE OF BIRTH Carmel, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME JoAnn Cornish
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
16. FATHER
A. NAME Paul Simon
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Barbara Calvachio
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~LMENT
DEAlt
DE'CJH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
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
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best of my
as to my right to enter into the mama estate.
21. SIGNATURE OF GROOM~
o 0 1ST 0 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
owledge and belief that the information I provided is true and that I declare that no legal impediment exists
......, -~._., .
22. SIGNATURE OF BRIDE~ I. '~ ~--_.~~
,-' USE CURRENT NAME 08/23/2006
DATE
W
UJ
Z
W
(,)
::::i
USE CUR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bnde 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 C1IJ8fi't,K C. Master n 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
YEAR
by New York Domestic
~
{ SEAL }
"-v-'
TIME
MONTH
YEAR
MONTH
08/23/200
DATE
ppinger Falls, NY 12590
SIGNATURE ~
MAI~ 1OOffdll3
22 2006
24
2006
10
03:5S;~
08
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
10 AM Ot'/ ~ ':!> 00
PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER,
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
STATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~c~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY POVG::\t~-f..f~lE AI 'I
TITLE f*- 37M--
DATES~r..-tnu;t. ;...~ 1~()t6
/JIt-vv 7{) rz..tt- ;Z S'D e
STATE ZIP
31. WITNESS TO CEREMONY
SIGNATURE ~
MAILING ADORE S
/6 FZO($
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) /v\k.he...\ \~ L. S'~l'\()\'"\
SIGNATURE~ -1Jt;,~ d /~
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~