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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
G~O~~~Mach
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
Dutchess
COUNTY Wbpt;i
flVVI
CITYr;O~
DISTRICT
~~~I~~~R 100
NUMBER
I
11. A.
L 0 SUPPLEMENTAL FILE
Ta ~~1rt1~IDE
FULL NAME ryn e
FIRST MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
..
N
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
. (OPTIONAL - SEE REVERSE)Q28.66.8'74O
D. SDCIAL SEca~useas BIisfo1
2. RESIDENCE A. (STATE)'; B. (COUNlY)
C. ~gCK ONRayriMffi' 0 TOWN 0 VILLAGE
SPECIFY 434 Churcti street
D. STREET ADDRESS ZIP
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORATEO~GE? 1 ffl
3. A. AGE 3B. DATE OF BIRTH /
MONTH DAY
4. EMPLOYMENT Occupslianal Therapist
A. USUAL OCCUPATION 11.1.11111 II." Myt.
B. TYPE OF IND~'IIlirliii. M IId'ItA.
5. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER Matthew LoI.is stelmach, Jr.
A. NAME USA
B. COUNTRY OF BIRTH
B. BIRTH NAME (MAIDEN NAME), ~RE~
C. SURNAME AFTER MARRIAGE m
(OPTIONAL - SEE REVERSE) 119-62-4368
D. SDCIAL SE~Bfil t'RM
12. RESIDENCE A. ana B. deI1Ce COUnty
(STATE)., (COUNTY)
C. ~~gCK O~rthCP~cirW:'r 0 VILLAGE
SPECIFY 53 CoIurnbu5 AVa],", 1# 402 02911
D. STREET ADDRESS ZIP .;
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORAYii'LLAGE?1\II 0 ~~ NO
13. A. AGE 13.B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
14. EMPLOYMENT Occupslional Therapist
A. USUAL OCCUPATION F....nf5 I-hNIth Cor.
B. TYPE OF INDtiM~ New YOI'k
15. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Raymond Anthony Vitale
A. NAME USA
B. COUNTRY OF BIRTH
al187.191B
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YEAR
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7. MOTHER Virginia SUsan Dunham
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
OIV'OCE CIVIL A~LMENT
17. MOTHER
Michaela Ellen Morris
A. MAIDEN NAME uSA
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D't)'RCE CIVIL A~ULMENT
D"()TH
Dt)TH
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
1ST 0 0 0 0
a: 2ND 0 0 0 0
W
lD 3RD 0 0 0 0
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0
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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 Sta named above by any person authorized by New York Domestic
Relations Law g11 to perform marriage ceremonies within 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.
{~} ~:~~~;:,:~c:wm: M~. ".',,:".N:'~"""O"'G:, MOO,,"
SEAL SI~T ~ . ~ &~lE~
M~ IS; ppnger Is, NT 12590 01'39 AM 08 10
"-v-I STREET CITYITOWN STATE ZIP' PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
~~~SM~~~~~~B~VJ~N Pi.fE TIME MO. DAY YEAR O,g"RELlGIOUS
DATE AND AT THE TIME AND Ntt
PLACE INDICATED. J:3l> PM 9 0 OTHER, SPECIFY
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNT'f'"1U:tUA.#H
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY !:AU ~
TITLE ~~
DATE -'. ovT...~
AI t;,
ZIP
31. WITNESS TO CEREMONY
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