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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J.,E Neal S~,ld, Jr.
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutcbess
CITYfTOWN Wappinger
~~~~kc~ 1368
~5~I~J~R 96
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A.
FULL NAME Lis~ ~8n Tribbli
R DLE
CURRENT SURNAME
CURRENT SURNAME
"'-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Bartko
c. SURNAME AFTER MARRIAGE C:cefield
(OPTIONAL. SEE REVER~
D. SOCIAL SECURITY NUMBER 105 52 2i78
12. RESIDENCE AN-.AV.9r:k B D~~~s
C. CHECK ONE 0 CITY 0 TOWN {J! VillAGE
~~~CIFYWappinger$ Fall$
D. STREET ADORESs4 Prnspect Stfeet ZIP12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES..tJ NO
13. A. AGE44 13.B. DATE OF BIRTH n.. ./.. .../..~
"'MflNTH lJ:-f DAY "1 Sti \'EAR
14. EMPLOYMENT
A. USUAL OCCUPATION Senior Mortgage Funder
B. TYPE OF INDUSTRY OR BUSINESS Fremont Imte~ & Loan
15. PLACE OF BIRTHY~~S~~~IF,(~rJsAI
16. FATHER
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 120 60 1164
2 RESIDENCE A N~T'tor:k B. ~II
C CHECK ONE 0 CITY 0 TOWN \Ill VilLAGE
~~~CIFY Wappingers Falls
o STREET ADDRESS 4 Pro~pp.r.t ~trp.p.t ZIP 17~Qn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
3. A. AGE42 3B. DATE OF BIRTH MWH / ZRy /1;Qj3
4. EMPLOYMENT
A. USUAL OCCUPATION Sheet Metal Wolter
B. TYPE OF INDUSTRY OR BUSINESS Lo~al ~8
5. PLACE OF BIRTH~~A~J_~ ~sXortf
6. FATHER
A NAME James Neal Scofield
B COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Jean Trimarchi
8. COUNTRY OF BIRTH 1I S A
8. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
A. NAMEArthur Franklin Bartko
8. COUNTRY OF BIRT" I 5 A
17. MOTHER
A. MAIDEN NAME Janet Josephine Young
B. COUNTRY OF BIRT"J 5 A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
DEATH
o
o 0 1 0
8. HOW DID LAST MARRIAGE END? (3)'tI DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) tr DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH03 / i? / ~1 C. DATE LAST MARRIAGE ENDED? ~g7 / ~ / 1 ~:J.l
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOllOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST OS/26/1993 Poughkeepsie, N Y 1ST 07103/1997 Poughkeepsie, New Yolt ~ 0
2ND 03/29/2001 pougbkeepsie, N Y 2ND 0 0
3RD 3RD 0 0
4TH 4TH 0 0
I, being duly SWDrn, depose the information I provided is true and that I declare that nD legal impediment exists
as to my rlghl to enter intD th ;' 1 "-,-/ fJn ,1
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ i11.:J.p. ~ I ~Y'J<..
/ " II Ii USE CURRENT NAME
23. SUBSCRIBED AND SWORW'fO' BEFORE ME 1/ DATE 08/2A/2005
SIGNATURE OF TOWN oR CITY CLERK ~ --------
This license authorizes the marriage in New Yor tate of the 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
7
~
{ SEAL}
'-.,-I
TIME
MONTH
YEAR
MONTH
YEAR
NAME (PRINT)
AM
PM 08
25
2005
10
23 2005
TA
27. TYPE OF CEREMONY
D ~ELlGIOUS
9 0 OTHER, SPECIFY
C ow
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
f(f3 ~~
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 ~lllAGE OF
,
SPECIFY VJtPf' i u (,E es" t=""V 1-<"'
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1 0 CIVil
29. OFFICIANT
NAME (PRINT)
'I' ;e.s f
SIGNATURE ~
MAILING ADDRE
.-5
ZIP
31. WITNESS TO CEREMONY
.-
NAME (PRINT) J C)
NAME (PRINT)
SIGNATURE ~
n(')~.QA 111 IQA\