106
+
f-
Z
W
UJ
W
1Il
C
-'
=>
0
:r:
UJ
z
0
~
c;
W
a:
W
~
ir
~
u.
0
W
5
ii:
~
W
0
W
a:
W 0;'
~ W
III
UJ 2:
UJ 51
W
a: Q
c ~
c
< tii
~ W
0 ~
W
D..
UJ
w
en
z
-w
u
-::i
+
~~~ W
~~i=
a: l< ~ !;(
\ii~~ U
=>ow
~<!l5 u:::
!z~UJ -
~~~ l-
ii:- a:
u.OUJ w
?~~ u
J!!~",
OW
zg~
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Mi~I~D~Eel Patrickc~~J~SURNAME
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNIY Dutchess
CITYfTOWN Wappinger
~~~~~~ 1368 .
~5~~~R 1 06
-.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lisa Ann Hamilton
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Incoronato
c. SURNAME AFTER MARRIAGE Ke IIv
(OPTIONAL. SEE REVERSE) 120-52-9295
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r:I TOWN 0 VILLAGE
~~CIFY WapQin9...er
D. STREET ADDRESS 30 Market Street ZIP 12512
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d' NO
10 /10 /f957
DAY YEAR
11. A. FULL NAME
D..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 085 62 3358
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STAT~ (COUNTY)
C. CHECK ONE I![ CITY 0 TOWN 0 VILLAGE
~~~CIFY PouQhkeepsie
D. STREET ADDRESS 9 Corlies Avenue ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r! YES 0 NO
11 / 10 / 1962
MONTH DAY YEAR
13. A. AGE 48
3B. DATE OF BIRTH
3. A. AGE 43
3B. DATE OF BiRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Process Engineer Tech
B. TYPE OF INDUSTRY OR BUSINESS IBM East Fishkill
15. PLACE OF BIRTH Manhattan, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Joseph Incoronato
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Francine Rega
B. COUNTRY OF BIRTH USA
;:S
18. NUMBER OF THIS MARRIAGE
W
!<
4. EMPLOYMENT
A. USUAL OCCUPATION Equipment Operator 3
B. TYPE OF INDUSTRY OR BUSINESS Dyno Nobel, Inc.
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Patrick Thomas Kelly
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ruth Ann Mary Schryver
B. COUNTRY OF BIRTH U S A
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO,CE CIVIL ANNOLMENT DEAlr DIV~RCE CIVIL AN~LMENT D~
~ ~
B. HOW DID.LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT 2~81DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVOR1j8 (3) O~ULMENT 2db~ DEATH
C. DATE LAST' MARRIAGE ENDED? 06/ 07 / C. DATE LAST MARRIAGE ENDED? / /
MONTH .,I DAY YEAR MONTH .,I DAY' '. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
(MO~6 1\ D7AY", YOEAORt p(ClTYtcqUNTYk ,STATEfPOUN;[FjY, IF NQT,U~ SELF SPOUSE (~.wrJ, llt\Y1 :t.~~ P (ClTYtcpljNTY. STATE/COU~Y, IF "tol USN SELF SPO~
1ST Jo/lJ I~ 1 ougn eepsle, New YOrK 0.,1 0 1ST ULl1bl ~~U ougnKeepsle, New YOrK 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affinn, aep'ose and ledge and belief that the Infonnation I provided is true a legal im~diment exists
as to my right to enter into the
21. SIGNATURE OF GROOM.
23. SUBSCRIBED AND SWORN TO/AFFIRM
SIGNATURE OF TOWN OR CITY CLER 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 pertonn 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 urpose of a second or subsequent ceremony.
r-"-. 24. TOWN OR CITJ<6Lft~ C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
07/25/200 TIME MONTH YEAR MONTH
SEAL SIGNATURE~ . DATE
'-v-I MAIL2Ie'fOOEIafe ppinger Falls, NY 12590 03:1(~ 07 26 2006 09 23 2006
ZIP
YEAR
STREET CITYITOWN STATE
~~R~~RT~~~ ~~O~~N:.z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME AY YEAR 0 0 RELIGIOUS 1 ~ CIVIL
DATE AND AT THE TIME AND M 0 Q' 0"" AI I'
PLACE INDICATED. .. 3t> PM 0 ,,) u t7 9 0 OTHER, SPECIFY
::&.':'= ~=. ~~C#AI~LL ~~ I~L7/G€ c.
SIGNATURE~ /J._d~ DATE 2 Is-I t?b
MAILING ~.!'ESS . ~ / I
t{j ,-".~rI11 ON Sf: tJt4C/6B177~S tvy I~ 'f77
STREET CITYfTOWN ST"iiE" ZIP
31. WITNESS ~EMONY
,
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNIY ULS'IE/e
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY S'Aut:;el< TICS
NAME (PRINT)
SIGNATURE~
OOH.98 (03l2DD6)
SIGNATURE