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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Evan Simon
tilAI~ t"11.t:. NUMtsCn
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYITOWN Wappinger
~~~~kc~ 1368
~5~I~l~R 11
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Jaynie M - Scalice
FIRST MIDDLE
CURRENT SURNAME
11. A.
MIDDLE
CURRENT SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Simon
(OPTiONAL. SEE REVERSE)075-68-6785
D. SDCIAL SECURITY NUMBER
12. RESIDENCE ANew York B Bronx
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Bronx
D. STREET ADDRESS 112-tll::dgewater Park
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 28 13.B. DATE OF BIRTH 08 ;t8
ZIP 1 U4ti~
..,
o YES 0 NO
1)177
DAY YEAR
Il-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)103-58-7858
D SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B Rockland
(STATE) J. (COUNTY)
C CHECK ONE 0 CITY [J TOWN 0 VILLAGE
~~~CIFY Suffern
D STREET ADDRESS 34 A LeXington Avenue
109U1
ZIP
wi'
YES 0 NO
/1961
YEAR
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE44 3B. DATE OF BIRTH 12 /05
MONTH DAY
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Hairdresser
B. TYPE OF INDUSTRY OR BUSINESS Hair Salon
15 PLACE OF BIRTH Peekskill, New York
(CITY, STATE/COUNTRY IF NOT USA)
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4. EMPLOYMENT
A. USUAL OCCUPATION Detective
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Jack Scalice
B. COUNTRY OF BIRTHU 5 A
17. MOTHER
A. MAIDEN NAME Georgina Moreno
B COUNTRY OF BIRT~uerto Rico
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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6. FATHER
A. NAME MeMn Simon
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Yvonne Buria
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
1 0
(2) 0 DEATH
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (00 DEATH
C. DATE LAST MARRIAGE ENDED? 06 / 26 / 20 2
MONT~ 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
1ST 06/2612002 Rockland Co., New York 0 rS
2ND 0 0
3RD 0 0
4TH
I, being duly sworn, depose an ,
as to my right to enter into the marn ge
21. SIGNATURE OF GROOM ~
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. 4RE 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
o 0
o 0
o 0
o 0
nd that I declare that no legal impediment exists
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23. SUBSCRIBED AND SWORN TO BEF
SIGNATURE OF TOWN OR CITY CLERK ~
This .Iicense 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.
~ } ~:';;';:,~:,OJ.h~~ "~,:~"""::,:'''~o "G~:"
{SEAL SIGNATURE ~ ~~.. DATE 03/15/2006
'-y-I M~'Mrami:bush Rd,Wappinger Falls, NY 12590 12:44 ~~ 03 16 2006
STREET CITY/TOWN STATE ZIP
~~~R~~~R;~~ 10~O~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR RELIGIOUS 1)(j CIVIL
DATE AND AT THE TIME AND ~ / "-
PLACE INDICATED. PM
05
14 2006
by New York Domestic
MONTH
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTV (;1-~
29 OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF fi TOWN OF ,0 VILLAGE OF
SPECIFY F Ie;Ak!/ /
~e.---