108
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
2 0 0 1 0 0
B. HOW DID LAST MARRIAGE END? (3) dDIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) D"DIVORCE (3) 0 ANNULMENT (g), 0 DEATH
C. DATE LAST MARRIAGE ENDED? 10/ 23 / 1996' C. DATE LAST MARRIAGE ENDED? 12 / 14 / 1988
MONTH.... DAY YEAR MONT':i.I DAY. . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 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, YEARl (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY1 YEAIj) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 05/05/198t1 Lonoke CO., Arkansas ct 0 1ST 12/14/ 99ts Poughkeepsie, New York 0.... 0
2ND 10/23/1996CumberlandGo.,N.G.. 0.... 0 2ND 0 0
3RD 0 3RD 0 0
4TH 0 4TH 0 0
I duly swear/affirm, depose and say, that to t ledge and belief that the information 1 provided is true d that I ~eCI~are~hat no Ie a1 impediment exists
as 10 my right to enter into the marnage e. . "-
\
21. SIGNATURE OF GROOM ~ "ZSIG ATURE OF BRIDE ~
L USE CURRENT NAME 07/2b~/2006
23. ~~:~~~~Do~N.fo~~Oo~N 6~A~FIR t ~;' f.C.< ~ DATE
This license authorizes the marriage in New York 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 only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITYJCI,ERK C M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) onn . asterson
{SEAL SIGNATURE ~ DATE 07/26/200 TIME MONTH YEAR MONTH DAY YEAR
'-t-' MAI~ 1\7n appinger Falls, NY 12590 05:5~~ 07 27 2006 09 24 2006
ZIP
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
,{; 5 0 AM (.2 ':2fJe (,.
29 OFFICIANT.....-77- . . C-", 77~' .LI r .--:l
NAME (PRINT). ~ r c::>~. tP I - ~n;..' , TITLE VA-<(' ~
SIGNATURE ~~ ~ DATE ?-/t-.2./?~",
MAILING AD~ '
/ )"??- JAA d." /2 S'" tIJ&?e A.Ll4f '~ tu'X-./JI7 r" .u-P..u? f ,c;di,. N f/ (2 rP 0
STREET / CITYITOWN ~ ---r=- STATE ' ZIP
30. WITNESS TO CEREMONY 31. WITNESS TO C~MO~Y
NAME (PRINT) R 0 NAME (PRINT) ..JJ;lQe'.\ 0
+
0-
Z
W
(/)
W
III
o
...J
::>
o
J:
(/)
Z
o
;::
~
0-
en
a
UJ
a:
UJ
Cl
<(
cr
a:
~
u.
o
UJ
0-
<(
(.J
IT:
>=
a:
w
(.J
us
a:
us
J:
;:
:J)
:J)
.1J
J:
::l
::l
<(
~
'-
3
u
~
n
+
~~~ W
-;:0- ...
~~~ CC
;;~~ 0
::l(.Jw
::E(!l5 u:
-zoo _
~~15 ~
to(/) w
:>0->
ii~C5 0
-ffill'l
~g~
~ 11"\ I a:: ur .,,1:. VV T Ut'U\.
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tlfhin .Joseph nallzat, .Jr
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN WappinQer
~~~:~c~ 1368 .
~~~~;~R 1 08
1 . A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 436 15 0350
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A. New York B. Dutchess
(STAT~) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 134 Innis Ave., Apt. K1 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? rf YES 0 NO
06 / 17 / 1962
MONTH DAY YEAR
3. A. AGE 44
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Service Technician
B. TYPE OF INDUSTRY OR BUSINESS Iner!:w, L P
5. PLACE OF BIRTH Shawnee, Kansas
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Tubin Joseph Dauzat. Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joyce Marie Lacombe
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
w
en
z
w
o
:i
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
~;OUS
9 0 OTHER, SPECIFY
(THIS SPACE FOR STA TE USE ONL Y)
~
-'.-
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
-1
11. A. FULL NAME Regina Marie Houston
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Ga ruti
c. SURNAME AFTER MARRIAGE Dauzat
(OPTIONAL - SEE REVERSE) 060-54-2220
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 69 Fieldstone Blvd. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES 6 NO
13. A. AGE 46 3B. DATE OF BIRTH 07 /20 A960
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Accounts Payable MQr.
B. TYPE OF INDUSTRY OR BUSINESS J. D. Johnson Co.
15. PLACE OF BIRTH Cold Spring, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Carmelo Garuti
'B. COUNTRY OF BIRTH Italy
17. MOTHER
A. MAIDEN NAME Concetta Giachinta
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 2
DEATH
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY 'Yu 'rClvJ<
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY ~(~/?
SIGNATURE~