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1. A. FUll. NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST .lnJrlo&1i('h~F!1 nam~f SURNAME
I
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c~ 1368 .
~5~1~~R 84
L D SUPPLEMENTAL FILE
FROM THE BRIDE
~~Dfi!' Ann I ;:! ~~RENT SURNAME
.J
11. A. FUll. NAME
FIRST
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE I ;:!~~i - n;:!mpf
(OPTIONAL' SEE REVERSE) 049 72' 5843 (OPTIONAL. SEE REVERSE) 108 66 7973
D. SOCIAL SECURITY NUMBER ___ - __ - ____ D. SOCIAL SECURITY NUMBER _ __ - __ - __ _
2. RESIDENCEA. NF!w York B. nllkhess 12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY &' TOWN 0 VILLAGE C. CHECK ONE 0 CITY [J" TOWN 0 VILLAGE
~~~CIFY Wappinger ~~CIFY Poughkeepsie
D. STREET ADDRESS 209 PODula Blvd. ZIP 12590 D. STREET ADDRESS 14 Romca Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VIllAGE? 0 YES r:! NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIllAGE? 0 YES r::1 NO
3. A. AGE ?7 3B. DATE OF BIRTH On / 05 / 1979 13. A. AGE 25 3B, DATE OF BIRTH 02 /20 /1981
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Bank Teller
B. TYPE OF INDUSTRY OR BUSINESS Wachovia Bank
5. PLACE OF BIRTH New Haven. Connecticut
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Michael Henry Dampf
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Louise LeBlanc
B. COUNlTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENIT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Monroe-woodbury Schl.
15. PLACE OF BIRTH PouohkeeDsie: New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Joseph D. Lassi
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Elizabeth Tompkins
B. COUNlTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
(2) 0 DEAJH
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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 AGAINST WHOM
(MONTH, DAY, YEAR) (ClTYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say
as to my right to enter into tile m
21. SIGNATURE OF GROOM.
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
t of my knowledge and belief that the information I provided is true an
o 0
o 0
o 0
o 0
pediment exists
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 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.
r-I'-.. 24. TOWN OR~ CITYJC. RK "'. . 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) 0 .' _ _
{SEAL SIGNATURE ~.. DATE 06/28/200 TIME MONlTH YEAR MONTH
'-v-' MAI~1OOffd~bush Rd, Wappinger Falls, NY 12590 06 29 2006 08 27 2006
STREET ClTYrrOWN STATE
~~~R~~Ri':~ lo~O~N:.zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME O. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
DATE
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~TCJh:8i
C.
29. OFFICIANT
NAME (PRINT)
z., .oS Pi..
"'" I nD ,,..,, ....,n^~\