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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COUNTY Dlltr.he~~
CITYfTOWN WfJppingp.r
~~~:~cJ 13f\R
~~~I~J~R 6~
1. A. FULL NAME
C~epher Rim.,al Pashe~RENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 060 SB.- 3592
2. RESIDENCE A. N..~ er-k B. Q_ess
C. CHECK ONE 0 CITY liif TOWN 0 VILLAGE
AND W .
SPECIFY Bpplnger
D STREET ADDRESS 92 Osborne Hill Rd Apt AOIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES i!l NO
MOW / ~~ / y;lD72
3. A. AGE 34
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Machine Operater Driver
B. TYPE OF INDUSTRY OR BUSINESS Town Of Pleasam Valley
5. PLACE OF BIRTH Rrt'lny NII:IUI V t'lrIt
~I~!;T'A~ lC'c:mM"R7if?'~ USA)
6. FATHER
A. NAME Edgarde A. Pashese
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Myma Borras
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 7
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04 / "6' / .,nn5
MONTH D~ ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? MES 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
1 ST 04/06/1005 POLlghkeep~ie, f\lew York
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best of my kn
as to my right to enter into the marriage state. f
21. SIGNATURE OF GROOM~
.., I '" I ~ rll_1: l.umD~n
(TH/S SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Due Spfingllif!
~
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~clW.t.~~~~~~sraeAeee
D. SOCIALSECURITYNUMBER 057 62 6519
12. RESIDENCEA. N.~er:k B. ~ss
C. CHECK ONE 0 CITY [ill> TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 92 O~borne Hill Rei
Apt P.7ZlP 12~90
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES I'i!l' NO
Wb 1aAY 1'91&
13. A. AGE 29
14. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Office Manager
B. TYPE OF INDUSTRY OR BUSINESS Dutchess County Pools
15. PLACE OF BIRTH ~IW~'1'E~~RYIP3 USA)
16. FATHER
A. NAME Jehn GeeFge Spfingman
B. COUNTRY OF BIRTH l' 5 A
17. MOTHER
A. MAIDEN NAME Carol Sue Pren
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
YEAR
o
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
at no legal impediment exists
USE CUR ENT NAME
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
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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
w
en
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()
:::::i
~
{ SEAL }
'-.-'
NAME (PRINT)
..
05/31 '2006
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
05'31/-2006
AM
06:07PM 06
01
2006
07
30 2006
ZIP
TATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
tJ6
;zr a-)
9~
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY () t/rcitr.Jl>
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF E1ToWN OF 0 VILLAGE OF
SPECIFYwr M.r~?-r
1~VIL
NAME (PRINT)
SIGNATURE~