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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Yuji Nakano
I
(THIS SPACE FOR STA TE USE ONL Y)
:;IAII: riLl: l..u..n;~L.n
Dutchess
COUNTY W
applnger
CITYfTOWlll
DISTRICT '1 368
~~~~~~R 75
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11 A. FULL NAME Suzanne ~tellini
FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
MIDDLE
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Stellini
c. SURNAME AFTER MARRIAGE Nakano
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER nR1-f14..3514
12. RESIDENCE A N Y B Dllt,.h~SS
(STATE) ~
C. CHECK ONE 0 CITY f'i TOWN 0 VilLAGE
AND W .
SPECIFY aDDlnger
o STREET ADDREss5 Dorothy Heignt~ ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ollI NO
13. A. AGE42 13.B. DATE OF BIRTH "1 ../- ".1.6'1.
"lJONTH lJ-/ DAY .tlt ~AR
14. EMPLOYMENT
A USUAL OCCUPATION Real Estate Agent
B. TYPE OF INDUSTRY OR BUSINESS Wp.ir.hert Realtors
15. PLACE OF BIRTHManhattan, Np.w Vnrtr
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAMEFrank Stellini, Jr
B. COUNTRY OF BIRTtlJ S A
17. MOTHER
A. MAIDEN NAMEBhel start
8. COUNTRY OF BIRTU ~ A
18. NUMBER OF THIS MARRIAGE 2
0-
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)562-15-7636
D. SOCIAL SEC~ITfUMBER
2. RESIDENCE A. B. Ulster
(STATE)" (COUNTY)
C. CHECK ON. ,. hD. ClIY 0 TOWN 0 VilLAGE
AND nlg lana
SPECIFY 706 Rt
D STREET ADDRESS e. 44/:':' ZIP 12528
E. IS RE~CE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
3. A AGE 38. DATE OF BIRTH 09 /15 /1972
MONTH DAY YEAR
4. EMPLOYMENT C
A. USUAL OCCUPATION arpenter
B. TYPE OF IND~TRY OR BUS;SS ~elf-employed
5. PLACE OF BIRTH acrame 0, CalifOrnia
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER G A
A. NAME eorge sato Nakano, Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Carole Kiyo Tanaka
8. COUNTRY OF BIRTH U ~ A
8. NUMBER OF THIS MARRIAGE
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
1 n 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3)'6 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
/ / C DATE lAST MARRIAGE ENDED? n~ / 1&\ ~nn?
MONTH DAY YEAR MON!!;l ii'l( y "'!mi'
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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 0 0 1sT03/15/2002 Poughlrp.p.pltie, New York 0 vtJ
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the InformatJon I provided IS true an 0 legal impediment exists
as to my right to enter into the m rr a e s te.
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVfiRCE CIVil A'(fUlMENT
DEATH
DEATH
o
C. DATE LAST MARRIAGE ENDED?
a:
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21. SIGNATURE OF GROOM ~
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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 New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpDse of a second or subsequent ceremony.
24. TOWN OR J~ 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
MONTH
YEAR
~
{ SEAL }
'-v-I
TIME
YEAR
DATP7127/2005
'nger Falls, NY 12590
STATE
27. TYPE OF CEREMONY
D 10" RELIGIOUS
9 0 OTHER, SPECIFY
~~NATURE
IlI!U-IMi
9
25 2005
ZIP
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
II ~ 00 M ~ ';).t> ~
p
10 CIVil
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTy~k<:;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [B" TOWN OF 0 VilLAGE OF
SPECIFY +ISHKf\.-b4
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
~~~:~~~~~T ~~~ ' ~!3..t<ANR- --:\~ TITLE E'LJ::e r<.
SIGNATURE ~~ [~f( mote ~~ 'fi DATE
MAILING ADDRESS
/q "=FEtJr{'(:;t(6- ~I \3e, W A-rPIAr'~ "f1J11<' }.j...J-
STREET ~ CITYfTOWN 10!:9 St.TE
30. WITNESS TO CEREMONY
/l '--t3c!<-T UV00 u /C-fi
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1.J.St 0
NAME (PRINT)
SIGNATURE ~
SIGNATURE~
DOH.9B (11/98)