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COUNTY Dutcb~
CITYfTQWN Wappinger
DISTRICT 1368
NUMBER
REGISTER 80
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME DhilsP ~""
~ WJ' MIDDLE
11. A.
FROM THE BRIDE
FULL NAME ROMnn ~i~ flIacJth '''''
F 5T MIDDLE
CURRENT SURNAME
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT ,..
C. S~SM~JN~~~~~~~e~~l!adcbum - Pel'QV
D. SDCIALSECURITY NUMBER 59?-43-3415
12. RESIDENCE A'NerfA~pdc B. ~
C. CHECK ONE 0 CITY tl TOWN 0 VILLAGE
AND G .
SPECIFY AI'IMInft
D. STREET ADDRESS 18A-" RftlJtA g ~ B ZIP 1052.1
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE28 13.B. OATE OF BIRTH 'In 1.9 1~
-----u'l'NTH DAY. ~R
14. EMPLOYMENT
A. USUAL OCCUPATION ShuW'lt
B. TYPE OF INDUSTRY OR BUSINESS BAny UnlvAI!IdtV
15. PLACE OF BIRTH GI'AI'YItta At ~
(~Y~
16. FATHER
A. NAME ~~ R1~lm
B. COUNTRY OF BIRTfoGl'AftAdA
17. MOTHER
A. MAIDEN NAME Mergaret Nimbi.
B. COUNTRY OF BIRT~fANIdA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIALSECURITYNUMBER 087-88-7613
2. RESIDENCE A. N1M;t- B. ~II
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND Ga'
SPECIFY I11flV'
D. STREET ADDRESS 1885 p".. 9 AP B ZIP 1~'4
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 30 3B. DATE OF BIRTH M9A / ctiv /1,175
4. EMPLOYMENT
A. USUAL OCCUPATION 8ectricea ~fleM'
B. TYPE OF INDUSTRY OR BUSINESS E"'SW
5. PLACE OF BIRTH <?~u& ~
6. FATHER
A. NAME NcboIas p~",
B. COUNTRY OF BIRTH G~
7. MOTHER
A. MAIDEN NAME MaureeR Marla Cooper
B. COUNTRY OF BIRTH G~
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? .j3)I:J.D~VORCE (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 ANNULEO, 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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DEATH
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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
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the
a5 to my right tD 'enter into the marriage state.
21. SIGNATURE OF GROOM ~
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IGNATURE OF BRIDE ~
/
DATE MID4I2OO5
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 Stat of the bride and groom named above by any person authorized
Relations Law ~11 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.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-y-I
YEAR
MONTH
YEAR
TIME
MONTH
NAME (PRINT)
SIGNATURE ~
MAILING A~DRESS
DATE MID4I2OO5
AM
03:43 PM 08
10
03 2005
05
2005
ZIP
STATE
27. TYPE OF CEREMONY
o [jY'RELlGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY1Jttfl!;H!S
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TiME AND
PLACE INDICATED.
10 CIVIL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [I(' TOWN OF 0 VILLAGE OF
W I1ffl'tJ G r-R
TITLE P A-S-/-;Y-Y
DATE tl/(I,//;~"
C.
STATE
SPECIFY
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT~~D~= ~ ~ c...lC,Bi.J \i:It
SIGNATUAE~ . ~~
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)