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064 T"' 0 U) N T"' - ~ ~ ~ .... m ~ ~ CD f .... :;: ij ct Ii c Q. J wi! ~u.. -ct I Cl 13 w- F- I ti = t:: ~ F a: , w III ~ '" z 0 ~ <( lH ~ a: 13 .... w m Q. m W -en z -W 0 -- ...I ~~~ W "':;:- lii~~ .... ~ffiz ct ~Gi!j 0 ~Cl5 i! !z~m - ~~ts ti: itom W Ol-~ 0 W~O tiffi'" zg~ 0- N 1. A. FUll NAME STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM B.mamiR patReSegal I STATE FILE NUMBER (THIS SPACE FOR STA TE USE ONL Y) COUNTY Dllt~hp.~~ CITYITOWN Wapping~r ~~J:~~ 13f\R ~~~I:J~R f\4. ..J L 0 SUPPLEMENTAL FILE FROM THE BRIDE 11. A. FULlNAME Je.r Men... ~nrp.lli CURRENT SURNAME CURRENT SURNAME B. BIRTH NAME, IF DIFFERENT B. B1AlH NAME (MAIDEN NAME), IF DIFFERENT C. sttS~~fe"':~~~s?egal D. SOCIAL SECURITY NUMBER . nfif\..flf\..?Q!;2 12. RESIDENCE A. Nt;ll~or:k B. ~5S C. CHECK ONE 0 CITY I!f TOWN 0 VILLAGE ~CIFY pnllghkp.p.p~ip. D. STREET ADDRESS 2633 South Road; Apt H7 ZIP 12601 E. IS RESIDENCE WJniIN UMITS OF CITY OR INCORPORATED VIUAGE? 0 YES !'1 NO 3B. DATE OF BIRTH ~ 4~AY 19~ C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER 22S-49-6567 2. RESIDENCE A. N~WrEY 8Fk B. ~ell c. CHECK ONE 0 CITY Iii! TOWN 0 VILLAGE AND n k . SPECIFY rough eepsle D. STREET ADDRESS 26~~ ~nllth Rnad; Apt H7 ZIP 1 ?flO 1 E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YEs!!l NO MJR /!~ / JjR1 13. A. AGE 25 14. EMPLOYMENT A. USUAL OCCUPATION T p.a~hM B. TYPE OF INDUSTRY OR BUSINESS Wappinger Cntrl 15. PlACE OF BlATIH RhinebP~r-W'Y ark (CITY. STATE IIF NOT USA) 16. FATHER A. NAME George Cherl~~ t":irnnr~lli B. COUNTRY OF BIATIH 11 ~ A 17. MOTHERn A. MAIDEN NAME ~1I~8n I ynn Bean B. COUNTRY OF BIRTH l J ~ A lB. NUMBER OF THIS MARRIAGE 1 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT n n DEATH o 3. A. AGE 24- 4. EMPLOYMENT 3B. DATE OF BIRTH A. USUAL OCCUPATION Software Engineer B. TYPE OF INDUSTRY OR BUSINESS 16M t":()qJ 5. PLACE OF BIRTH rc~_~M~~~~~~ York 6. FATHER A. NAME Richard S. Segal B. COUNTRY OF BIRTH I) S A 7. MOTHER A. MAIDEN NAME Susanlomline Goeller B. COUNTRY OF BIRTH I) 5 A B. NUMBER OF THIS MARRIAGE 1 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT School DEATH n (2) 0 DEAlH B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEAlH 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) (CITYICOUNTY. STATE/CQUNTRY, IF NOT USA) SELF SPOUSE o o o o o B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / 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 1ST 0 0 1ST 2ND 0 0 2ND 3RD 0 0 3RD 4TH 0 0 4TH I duly swear/affinn, depose and say, that to the best of my knowledge and belief that the information I provided is t as to my right to enter into the m mage state. 21. SIGNATURE OF GROOM" . f.. 22. SIGNATURE OF BRIDE" USE CU 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 pu~ of a second or subsequent ceremony. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS DATE by New York Domestic ,-I'-.. { } NAME (PRINT) SEAL SIGNATURE ~ MAILING ADDRESS '-v-' . STR I CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF THE PER- SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND 7~/'L' AM PLACE INDICATED. . .. YEAR MONTH YEAR TIME MONTH AM 05:38PM 06 01 2006 07 3D 2006 ZIP ATE 27. TYPE OF CEREMONY o 0 RELIGIOUS 9 0 OTHER. SPECIFY 28. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNTY \{e~ \-i>~-k C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) ITY 26. SOLEMNIZATION OCCURRED TIME MO. DAY YEAR 1~ CIVIL 2" 6 0(, WA8l~~~~ M\c\-\t\f.L. (.( R,ENZO SIGNATURE~ n1cuhJ i? I~ MAILING ADDRESS ltn n\\\.L ''1 ~1I6\..tI(f~rlS't STREET CITYITOWN 30. WITNESS TO CEREMONY TITLE N\\~n"1'(~ DATE cb~d'I,06 ~ STATE ~'\\or NAME (PRINT) SIGNATURE~