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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
\NIlli:rC~J~in.<it~OM
I
STATE ALE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
Dutchess
COUNTY WIIpp
C;ITVfTO~ nger
DISTRICT 368
NUMBER f!f1
REGISTER
NUMBER
L D SUPPLEMENTAL FILE
Michell~'i.~l~.gIDE
11. A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
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N
B. BIRTH NAME (MAIDEN NAME), ~NT
C. SURNAME AFTER MARRIAGE ~
(OPTIONAL - SEE REVERSE~""
D. SDCIALS~BJk ~
12. RESIDENCE A. (STIIll'E) B. (COUNlY)
C. CHECK CM-.._.LJLr~ TOWN 0 VILLAGE
AND rUUWI~v
SPECIFY 2883 Mulberry Court
D. STREET ADDRESS
E.
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~
(OPTIONAL - SEE REVERSE09~
D. SOCIALSE'fIi!Wurcitc Dutc1.-s
2. RESIDENCE A. (STATE) r,I B. (COUNlY)
C. ~~6CK OOWa~ri8rD TOWN 0 VILLAGE
SPECIFY 30 Mac Intosti l.8ne 12598
D. STREET ADDRESS ZIP .;
E. IS R~CE WITHIN UMITS OF CITY OR INCORPORATE~GE? ~D YES ~
3. A. AGE 3B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
4. EMPLOYMENT CUstamer E .neer
A. USUAL OCCUPATION I. B.1.
B. TYPE OF IND~.ga.~... ~ YOlk
5. PLACE OF BIRTH ruuw"......,...,
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER \NIIliam Paul Penk
A. NAME USA
B. COUNTRY OF BIRTH
12603
ZIP ~
...
IS R~NCE WITHIN LIMITS OF CITY OR INCORPORAl1@t'ILLAGE'ltc 0 i~ NO
13. A. AGE 13.B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
14. EMPLOYMENT
Teacher
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESS. D. U. F.
15. PLACE OF BIRTH pouf,bkeepsi.e.
(CITY, STATE/COUNT Y IF NOT USA)
16. FATHER Joseph Leonard Sauter, Jr.
A. NAME USA
B. COUNTRY OF BIRTH
s. D.
NY
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17. MOTHER Rosemary Annette D' Angelico
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
DtrRCE CIVIL A'GULMENT
7. MOTlHER Merle Irene SoltysIak
A. MAIDEN NAME Germ
B. COUNTRY OF BIRTH 1 any
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DlVCCfCE CIVIL A'UULMENT
DlOTH
D;)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
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, STATE/COUNTRY,IF NOT USA) SELF SPOUSE
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o 2ND 0 0
o ~D 0 0
o 4TH 0 0
ledge an lief that the information I provided is true and that I declare that no legal impediment exists
"...z2" . SIGNATURE OF BRIDE ~-1'Ytt..l (.( 1 ()Clf A(lA;.,~
USECURR~~~~
23. SUBSCRIBED AND SWORN TO BEFORE ME uar~,~
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with 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 C~. Mesterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME(PRI~T) ~
SEAL SI~Tlle . "-1?1___ (J...... <.. ..~lE osr. TIME 07MONTH
M1!!UM ~ \4iPiJnger FilS, NT 12:)90 12:07 AM
'-.,-I . PM
STREET CITYITOWN STATE ZIP
~~~R~~~R:~~~ IO~O~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TY..5 OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ELlGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. ()6 9 0 OTHER, SPECIFY
21.
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25. B. SOUEMNIZATION'PERIOD
ENDS AT MIDNIGHT ON:
YEAR
MONTH
DAY
YEAR
08
29 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY "])U~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY WAPfJIIJlCE..e.s F/ff.I..-s
29. OFFICIANT
NAME (PRINT]
TITLE
DATE
7~
SIGNATUR