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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Vi" Mllnuel ~IIII
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COUNTY Dutehess
CITYfTOWN U'f8pp1nger:
DISTRICT · ·
NUMBER 1368
REGISTER 66
NUMBER
1. A. FULL NAME
CURRENT SURNAME
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B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 129 66 1962
2. RESIDENCEA. N.~Bfk B. QIiGl1,SB
C. ~~6CK ONE D CITY,jjjiI TOWN D VIlLAGE
SPECIFY V\IapIinger
D. STREET ADDRESS P. O. BcIc 464 ZIP 12S90
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? D YES oil! NO
3. A. AGE 28 3B. DATE OF BIRTH Mai /25;. / 'tWJ
4. EMPLOYMENT
A. USUAL OCCUPATION MechaRlc
B. TYPE OF INDUSTRY OR BUSINESS MIRICIe Ford
5. PLACE OF BIRTH W~R" .IIY
6. FATHER
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A. NAME \A_a PacIIle
B. COUNTRY OF BIRTH PueIto Rlc:o
7. MOTHER
A. MAIDEN NAME Qt. st. George
B. COUNTRY OF BIRTH US,.,
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
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(2) D DEATH
(3) D ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
'I
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME 011_" MIlIi. ~~
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CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~lle
(OPTIONAL. SEE REVER~
D. SOCIAL SECURITY NUMBER elM &Ii 6204
12. RESIDENCE A.t-J.A~pIk B. ~~~I
C. CHECK ONE D CITY 'i1 TOWN D VILLAGE
AND Wa .
SPECIFY , pp1nge1'
D. STREET ADDRESS P. o. Box * ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
13. A. AGE23 13.B. DATE OF BIRTH '\2NTH 15DAy 1881.R
14. EMPLOYMENT
A. USUAL OCCUPATION ~ HUlSe
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH~~X. USA)
16. FATHER
A. NAME em-.rei "11lam. Ctjlen
B. COUNTRY OF BIRTf-l' S A
17. MOTHER
A. MAIDEN NAME Rosemarie ,tnA \.~eGGhIo
B. COUNTRY OF BIRT~ S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the marr.'
21. SIGNATURE OF GROOM ~
D D 1ST
o D 2ND
D D 3RD
D D 4TH
ledge and belief that the information I provided is true
D D
D D
D D
D D
pediment exists
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta 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.
D If checked. this license is to used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
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NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
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S
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
. SIGNATURE OF BRIDE
TIME
MONTH
YEAR
MONTH
YEAR
AM
PM
06
30
2005
08
28 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF D VILLAGE OF
SPECIFY ?OUGI-I !{~P41 t;.
NAME (PRINT)
SIGNATURE~