033
o
m
ID
N
..-
>=-
z
i
i
I
f
...
lIS
i
f
J
w
~
J:
~
U)
U)
w
a:
o
o
"
>-
lL
U
W
0-
U)
z z
a: 0 W
:0 >=
>- t-
w "
a: N <(
>- Z
U) ::; 0
:0 W
:; -' u::
0
>- U)
Z j::
" lL
U 0 a:
u:
lL U) W
0 >-
" 0
Iii 0
.. "'
0
Z ~
1 A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
DMiP R. TerwMm.r
:SlATE FILE NUM"l:H
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYrTOWN Wappinger
~~~~~c~ 1368
~5~I~J~R 33
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
-.J
CURRENT SURNAME
11. A. FULL NAME BeQ~e R~e MIDDLE
CURRENT SURNAME
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT lmpemti
c. SURNAME AFTER MARRIAGE .Qi:2:z0 Te....fI.II.. Iter
(OPTIONAL. SEE REVERS~)~""'" - I I Y'I :J
D. SOCIAL SECURITY NUMBER 098 34-8348
12. RESIDENCE A. NY;STATE) B D.~33
C. X~5CK ONE 0 CITY 0 TOWN V VILLAGE
SPECIFY WappingeR Falls
D. STREET ADDREss4 Franklin Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? oIii'\ YES 0 NO
~TH {:lDAY ~R
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIAL SECURITY NUMBER 072 46 2464
2. RESIDENCE A. N"'TATE) B. ~S6
C. CHECK ONE 0 CITY 0 TOWN W! VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 4 Fn'lnklin str~ef ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? il YES 0 NO
MtU~ / ~1y / ta~3
13. A. AGE 63
14. EMPLOYMENT
13.8. DATE OF BIRTH
3 A AGE 52
4. EMPLOYMENT
38. DATE OF BIRTH
A. USUAL OCCUPATION Heusevlife
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~9H,gt)~~~ NOT USA)
16. FATHER
w
!;;:
>-
U)
A USUAL OCCUPATION Disabled
8. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH ~gy~m~~'N~'5'If York
6. FATHER
A. NAME Deminiek ImpeFati
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Helen Schaefer
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
l-
S;
<C
C
w-
",u.
:5u.
~<C
z
~
o
to
>-
>-
u
A. NAME Lee Terwilliger, Jr.
B. COUNTRY OF BIRTH U '3 A
7. MOTHER
A MAIDEN'NAME Cannella Peillu&&i
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
101
8. HOW DID LAST MARRIAGE END? 13) 0 DIVORCE (3) 0 ANNULMENT (2) [OloIDEATH
C. DATE LAST MARRIAGE ENDED? "0 / Ill;. / 'lonn
MONTtf ~ ~~
D. ARE ANY FORMER SPOUSE(S) ALIVE? \iifYES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
DEATH
100
8. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE 13) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? ""l / .. ~ /.. QQn
MONTH I A DAr ~A'f'(B
D. ARE ANY FORMER SPOUSE(S) ALIVE? I!!il'YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
a:
w
<ll
:;
:0
Z
o
Z
'"
>-
w
w
a:
>-
U)
1ST 12115/1999 Dutchesf: COYnty, ~ 0 ~ 1ST 05/09/1962 Dutchess Ceunt)., N{ [0/1' 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the m 'age state. . ,~
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ 6,.,~ .............~ .... :: 7~
" USE Cll1'lRENT NAME
DATE
w
en
z
w
o
:J
23. SUBSCRIBED AND SWORN TO 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 911 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
by New York Domestic
~
{ SEAL }
'-v-'
YEAR
MONTH YEAR
NAME (PRINT)
TIME
MONTH
AM
PM 04
06 18 2006
20
2006
28. PLACE WHERE MARRIAGE OCCURR~0
A. STATE NEW YORK 8. COUNT' . urr.k
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ;r1 VILLAGE OF
SPECIFY tJAf!V#"9FR5{;#;
CIVIL
NAME (PRINT)
SIGNATURE ~