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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
D.u;;~n Scott ~E
I"
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
C1TYfTOWN Wappinger
~~~:~CRT 1 :\68
~5~I~l~R 1 O~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Krj_ Oi Nobil~DDLE
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Am3
(OPTIONAL - SEE REVER~
D. SOCIAL SECURITY NUMBER 087 74-3731
12. RESIDENCE AN '(STATE) B. OLiGlilell3
c. ~~6CK ONE 0 CITY '" TOWN 0 VILLAGE
SPECIFY~ppiRger
D. STREET ADDRESs1 Sky Top Drive zIP12S9g
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES -'J NO
13. A. AGE39 13.B. DATE OF BIRTH ~NTH 12 DAY 197!iAR
14. EMPLOYMENT
A. USUAL OCCUPATIONTe8cher
8. TYPE OF INDUSTRY OR BUSINESSMt. Vernon City Schls.
15. PLACE OF B1RTf-Nav. i.~M~IF~~A)YOrk
16. FATHER
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 145-784289
2. RESIDENCE A. N XTATE) B. D~*ss
c. CHECK ONE 0 CITY ot!J TOWN 0 VILLAGE
AND W .
SPECIFY apPlnger
D. STREET ADDRESS 1 Sky Top Drive ZIP 1 ,~~O
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESo(] NO
3. A. AGE32 38. DATE OF BIRTH ~H /01,Y /1~
4. EMPLOYMENT
A. USUAL OCCUPATION Mer.hanic
B. TYPE OF INDUSTRv-oR BUSINESS Oyson Rar.ing
5. PLACE OF BIRTHeatterson.... New ,Iersp'y
(CITY, STATE/CuuNTRY IF NOT USA)
6. FATHER
A. NAME Donald Ams ~r
B. COUNTRY OF BIRTH U S 'A
7. MOTHER
A. MAIDEN NAME Joyce Allcroft
B. COUNTRY OF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
(J
12) 0 DEATH
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A. NAMEAndrew JOEeph Oi Nobile
B. COUNTRY OF BIRTU 5 A
17. MOTHER
A. MAIDEN NAMEKar-en VeFOAica Swatow,'
8. COUNTRY OF BIRT'lJ S 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
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, STATElCOUNTRY, 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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
of my knowledge and belief that the information I provided is true and that I declare that no legal Impediment eXists
~i.". "G'","",~' M~. ~ 11 fl~
_. _. /J USE CURRENT NAME
23. ~ ~ DATE
This license authorizes the marriage in New York State of e bride and groom named above by any person authorized by New York Domestic
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 CLE~!:S". 25. A. SOLEMNIZATION PERIOD BEGINS
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the be
as to my right to enter into the m~t;1
21. SIGNATURE OF GROOM ~ .
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{ } NAME (PRINT)
SEAL SIGNATURE ~
~~I~iddl~S
'-.,-I STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DAY
YEAR
MONTH
YEAR
TIME
MONTH
07
2005
1
05 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AN~PECIFY)
o CITY OF [JfTOWN OF 0 VILLAGE OF
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
ZIP
31. WITNESS TO CEREMONY .
NAME (PRINT) E rl co.... 1) ~ N_9. b I l-e....
SIGNATURE ~ CiLif Ou !JJ[Jjci!JrL