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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Eric Scott Simone
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYrrowlJ WBppnger
DISTRICT 1 ~
NUMBER
REGISTER 13
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Courtney Marie PaoIilli
11. A. FULL NAME
FIRST MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
ll.
N
B. BIRTH NAME (MAIDEN NAME), Ifj'FFERENT
C. SURNAME AFTER MARRIAGE mone
(OPTIONAL - SEE REVERSE) 111-tu-wL6
D. SOCIAL SEilftlTY N'~ DUtCh
12. RESIDENCE A. f!JN B. ess
(STATE)" (COUNTY)
C. CHECK Olli. .__.llL~Il." 0 TOWN 0 VILLAGE
AND VViI~n~
SPECIFY 'M'I. H I -
OR on~ a..ano
D. STREET ADDRESS ZIP
E. IS RE!~CE WITHIN LIMITS OF CITY OR INCORPORATff4ILLAGE? 4--7 0
13. A. AGE 13.B. DATE OF BIRTH ~
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher ,..-<1
Dutch_ Comm. \.All.
B. TYPE OF IND~Y ~~~ New ortc:
15. PLACE OF BIRTH UUn p:Me, T
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER M . Joseph n..__"II.
A. NAME ano rau" I
B. COUNTRY OF BIRTHU S A
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - ,SEE REVERSE)l;l:>-fU-Ul:fUt)
2 :~S~:EC~~~ :EC~;:,grk B. DutcheSS
(STATE) r.ITY '!"': (COUNTY)
C. ~~5CK ONWaPii~ TOWN 0 VILLAGE
SPECIFY 39 ~ 1..8
D. STREET ADDRESS no ZIP
E. IS RES~CE WITHIN LIMITS OF CITY OR INCORPORATED 5fGE? 090
3. A. AGE 3B. DATE OF BIRTH /
MONTH DAY
12590
"
Y/~9f4
YEAR
12S90
.;
~NO
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Truck: Driver
B. TYPE OF INDUEie80R BUSI~i~~_'~~ex
5. PLACE OF BIRTH con, NeW 0
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME WeslfIf James Simone
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME ~e Tara Tempelaar
B. COUNTRY OF BIRTH SA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V'(SCE CIVIL ANtrLMENT
17. MOTHER
A. MAIDEN NAME Jacquelynne M. Green
B. COUNTRY OF BIRTHU S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D16'RCE CIVIL A"t)ULMENT
DroTH
DEtr
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
o 0
o 0
o 0
o 0
legal impe,diment.exists
1ST 0 0 1ST
2ND 0 0 2ND
~ 0 0 ~
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief tha1 the information I provided is true and that I declare tha
as to my right to en1er Into the rriage state. 1-1.
,. ..
21 SIGNATURE OF GROOM ~ . SIGNATURE OF BRIDE ~ .
URRENT NAME ""'I"Y.II~
23. SUBSCRIBED AND SWORN TO BEFORE ME UQ-'OlI-'\I\I\I
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York St of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi ew York State, THIS LICENSE VALID IN NEW YORK STATE ONLY,
o If checked, this license is t be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CI1Y L 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
"-v-I
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
04
24 2006
AM 02
12:34 PM
STATE ZIP
27. TYPE OF CEREMONY _./
1 tl"'CIVIL
24
2006
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
28. PLACE WHERE MARRIAGE OCCU~ _ .1_
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /"
o CITY OF 0 TOWN OF ~LLAG~" II _
SPECIFY W~~~
ZIP
31. WITNESS TO CEREMONY ~
NAME (PRINT) E ~,e,.. ~. · fA. ~ '-, '-'-,
C-- ~~
SIGNATURE~ . ~
.,"'.-