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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1. A FULL NAME ~8S Arthur Smith
FIR MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COuNTYDIItMacc.
CITYfTOWNWapt:inger
~~J~~~T1~
~5~lgJ~R47
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Sharon Lynn Scozzafava
FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Smith
(OPTIONAL. SEE REVERSE~ t:!oD1542
D. SOCIAL SECURITY NUMBER \1:.,;)"00"'
12. RESIDENCE ANew York B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFyWaDDinaer
D. STREET ADDRES~8E \NInthroP Court
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSElalU!' "7~ ~1Y'lo4
D. SOCIAL SECURITY NUMBER ]~L~~'_
2. RESIDENCE A. New Yark B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY.tJ TOWN 0 VILLAGE
AND Wa .
SPECIFY ppnger
D. STREET ADDREss28E Wnthrop Court ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? 0 YES~ NO
3. A. AGE27 3B. DATE OF BIRTH n~ /16 /1 Q7Q
~ DAY YEAR
DAY
ZIP12590
o YES~ NO
1m
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGi=?R 13.B. DATE OF BIRTH 06 01
MONTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Laborer
B. TYPE OF INDUSTRY OR BUSINESS laF81lJ8 Qypsum
5. PLACE OF BIRTHNorIh T.~ New York
(CITY, STATE/CO Y IF T USA)
6. FATHER
A. NAME David Monroe Smith
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dolores Alene Brennan
B COUNTRY OF BIRTH USA-
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATIONReceptionist
8. TYPE OF INDUSTRY OR BUSINESS TrumD N8t'I Golf Cub
15. PLACE OF BIRTHTawn or CortIancl. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEJaseph Louis &.uasfSV8
B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME~ Lup--..Jlo
B. COUNTRY OF BIRT.lJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNUUMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? /, /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY,IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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o 1ST 0 0
o ~D 0 0
o 3RD 0 0
o ~H 0 0
belief that the information I prOVid~d is t\')tnd that ~ de~e that no legal impediment exists
22.SIGNATUREOFBRIDE~
USE CURRENT NAME
23. ~~;~~~~DO~N-?o~~Ot~ ~'fvBg~ ~ DATE 05ID9I2006
This license authorizes the marriage e of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
21. SIGNATURE OF GROOM ~
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say. that to
as to my right to enter into the marriage s
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{ SEAL}
'-.,-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
ATE 05ID9I2006
SIGNATURE ~
MAILING ApDRESS
AM 05
12:08 PM
10
2008
07
08 2006
Falls NY 12590
STREET C /TOWN STATE
~~~R~~Ri~~~ 'o~O~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS 1 0 CIVIL
~tl~E ~~glc^:T;~E TIME AND . tJ 0 ~ 06 - 10 -.2 DD ~ 9 0 OTHER, SPECIFY
29. OFFICIANT /fE'll l/r~N"N W,GkRt:mI9Ttf/y'tfrF TITLE ~A,etJC~;I/""~ Vlc;19,e
NAME (PRINT) Y' r~
SIGNATURE ~ .t.:fi?~L-~Ir DATE 06-/0 ~ tJo6
MAILING ADDRESS ~= .
1.1/ GlN/d/V /P ViP .PE.€~S..et'~t.
STREET CITYfTOWN
30. WITNESS TO CEREMONY
n \.
NAME (PRINT) ....... '0 'If\.
"I
SPECIFY I'cc,l::.J'/(/~'
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTy)vIi.J7CNG,J',
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
[B"CITY OF 0 TOWN OF 0
VILLAGE OF
SIGNATURE ~
DOH-98 (11/98)
NY
STATE
SIGNATURE ~