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t A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mi~~ael Asber P~5es
I T MIO
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~J~f~ 1368
~5~I~J~A 1 09
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME ShWFI Mich811'1~8Re
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~~~~JtR~~~t~~e~~i86Ies
D. SOCIAL SECURITY NUMBER OB1 64
12. RESIDENCE ANewrXerk
C. CHECK ONE 0 CITY lilI TOWN
AND W .
SPECIFY applnger
D. STREET ADDRESs1 m; r.hiAl~iAA r.R'!j Z1P12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..tf NO
13. A. AGEJO 13.B. DATE OF BIRTH 1~NTH 1'1 OAY 19'74E"R
14. EMPLOYMENT
A. USUAL OCCUPATIONSeMce CC'ordinator
B. TYPE OF INDUSTRY OR BUSINEssDutcbeS5 ARC
15. PLACE OF BIRT~~~~N~.
16. FATHER
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 119-60-5654-
2. RESIDENCE A. N.A~Ork B. D~~5s
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
AND W .
SPECIFY applnger .
D. STREET ADDRESS 9 DQyle Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
3. A. AGE27 3B. DATE OF BIRTH MUH /2iy /1ftll
4. EMPLOYMENT
A. USUAL OCCUPATION r.nn~tnJr.tinn Work
B. TYPE OF INDUSTRY OR BUSINESsA V R Hnme RuilderE
5. PLACE OF BIRT..Manhasset, New V nrk
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME Harvay Michael Pa~~eR
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME MAry FItf1iAr Me Donald
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
DEATH
o
(2) 0 DEATH
6190
B.D_~s
o VILLAGE
A. NAMEGeorge Gregory Greene
B. COUNTRY OF BIRm J ~ A
17. MOTHER
A. MAIDEN NAME Rosalind Frances Connolly
B. COUNTRY OF BIRml 5 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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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
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
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH OAY 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 0 2ND
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is tru
o 0
o 0
o 0
o 0
legal impediment exists
21. SIGNATURE OF GROOM.
DATE 0910717005
by New York Domestic
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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 ~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.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo~
SEAL SI~NATU~5. S ,<p-C ~~ ---=-- DATef19m7I2nn~
'-v-I ~~'tiaf~6ush Rd, Wappinoer Falls, NV 12590
STREET c~ rrOWN ST ATE ZIP
~~~R~:Ri~~~ IO~O~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR ~ RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND ~ (l
PLACE INDICATED. i ~ PM I 0 (J 0 0 S" 9 0 OTHER, SPECIFY
~~~:j~~~~TRf" ~&~tJ MeJbrJ~ TITLE~
SIGNATURE. '..12_ ~o DATE to I t I ():r
MAILING ADDRESS ~ ~-:. t../t v I
79 M''Pp/1E" vdlt b'J r'#fJRTItPIIR ~.I, fl'J~7r
STREET CITYfT6WN' STATE
30. WITNESS TO CEREMONY
NAME (PRINT) QC\(\iO\ ~a, S~es
SIGNATURE. ,) Jlfw.-
DOH-98 (11/98)
rV",?SAV
YEAR
MONTH
YEAR
TIME
MONTH
2005
11
06 2005
08
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ,Rf VILLAGE OF
SPECIFY vJ E (, I Bod B..y'
vk S"T 9 VR. y filA N ~ Po. N.r:t r;c. 0