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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
F-*A ChllQiRt Jr.
COUNTY Dutchess
CITYfTOWN ~pplnger
~~J~~~T 1368
REGISTER 2
NUMBER
1. A. FULL NAME
CURRENT SURNAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 41>88-1924
2. RESIDENCE A. NMTr or:Ic 8. ~FSS
C. X~~CK ONE 0 CITY ., TOWN 0 VilLAGE
SPECIFY \NaR:inger
D. STREET ADDRESS 190 Pembroke CJrcle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Ii! NO
M01~ /~t /1~
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
3. A. AGE 47
4. EMPLOYMENT
3B. DATE OF BIRTH
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Michelle T. Taravella
FIRST MIDDLE
CURRENT SURNAME
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A. USUAL OCCUPATION ExcuIIve .~Iistant
B. TYPE OF INDUSTRY OR BUSINESS NIlVe Landsclplng
5. PLACE OF BIRTH ~~~FT~55-
6. FATHER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Chastain
(OPTIONAL - SEE REVERSE) I\IK!> ~1213
D. SOCIAL SECURITY NUMBER ~___
12. RESIDENCE A. New Vark B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY rr/ TOWN 0 VilLAGE
AND Wa .
SPECIFY ppnger
D. STREET ADDRESS 19 0 Pembroke Circle
ZIP 12590
DYES~NO
1S78
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 27 13.B. DATE OF BIRTH 03 111
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Artlngton Cb1. School
15. PLACE OF BIRTH Buff8la New' York
(CITY, STATi1!COUNTRY IF NOT USA)
16. FATHER
A. NAME Salvatore Robert Taravella
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME PlltrldA Ann Lorlnce
B. COUNTRY OF BIRTH USA
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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A. NAME Frank A Chastllin. Sr.
a. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME HI_ Ganett
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
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a. 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 I
DATE OF DECREE PLACE ISSUED AGAINST WHOM I
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
a! impediment exists
1ST 11J01J2001 Jasper, TenRIII.. [JI1I' 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 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
as to my right to enter into the m' tate.
G::
SIGNATURE. .
DOH-98 (11/98)
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK. DATE
This license authorizes the marriage in New York St 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 to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK , 25. A. SOLEMNIZATION PERIOD BEGINS
{ SEAL } ~~~~;;;~~~ DATE 0 m4f2(D TIME AM MONTH YEAR MONTH YEAR
'-v-I STR~ Middebllsb Rd, ~ FAlI!!;., ~TE12590 ZIP 03:1~M 01 05 2006 03 05 2006.
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY ~ 28. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER- ~
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS 1 CIVIL EW YO ...~ ~
DATE AND AT THE TIME AND A. STATE N RK B. COUNTY "'.'- trIG
PLACE INDICATED. 9 0 OTHER, SPECIFY
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a. HOW DID LAST MARRIAGE END? (3) MIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 11 / n1 / ?M1
MONTH DJ!f ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
1
21. SIGNATURE OF GROOM.
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C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF ~VILLAGE Ot=p l1.
ECIFY U)~/~JI.~
NAME (PRINT)
SIGNATURE.