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COUNTY Dllkhess
CITYiTOWN \/\lapping<<
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~5~~J~R 41
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JaEqftb~hrigtoptle~~NAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
A 0' A r. n
o mL~ .nn va~!;NT SURNAME
.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~JN~~~~rt~~e~~SE) 80nini
D. SOCIAL SECURITY NUMBER 072-0& 3738
12. RESIDENCEA N~EYork B qJ&~eliE
C. ~~5CK ONE 0 CITY D.;OWN 0 VILLAGE
SPECIFY Poughk':ep&ie
D. STREET ADDRESS 2301 South Road #23
ll.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 1201i6-4512
~)Ygr:k B. ~'MiE
o CITY D;TOWN 0 VILLAGE
PQugt:tkeepsie
o STREET ADDRESS 2301 South Road #23
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
2. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
ZIP 12$01
YES [lIIND
/1Q&1
ZIP
o
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MJ)a / ~a
13.B. DATE OF BIRTH
13. A. AGE 24
14. EMPLOYMENT
3B. DATE OF BIRTH
3. A. AGE 25
4. EMPLOYMENT
A USUAL OCCUPATION Compt.'t8r Technician
B. TYPE OF INDUSTRY OR BUSINESS t a. M,
5. PLACE OF BIRTH ~~~ Y~A)
6. FATHER
A. USUAL OCCUPATION .l\88isblnt Manager
B TYPE OF INDUSTRY OR BUSINESS Inn IV. Th. Falls
15. PLACE OF BIRTH ~rmLNM~.
16. FATHER
A. NAME ThamH RS}'mgnd Darr-agh
B. COUNTRY OF BIRTH US/',
17. MOTHER
A. MAIDEN NAME Rosemal')' Thomasine Felzer-eno
B. COUNTRY OF BIRTH U S l\
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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S;
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A. NAME RichaFd pasquale BaniRi
B. COUNTRY OF BIRTH U e /"
7. MOTHER
A MAIDEN NAME Mal)'ann Pacella
B. COUNTRY OF BIRTH US"....
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBEROF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
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
o 0
o 0
o 0
o 0
hat no legal impediment ex ts
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 S ,t at to the best of my kn
as to my right to'enter into the m rria
21, SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO B ORE ME
SIGNATURE OF TOWN OR CITY LERK ~ DATE
This license authorizes th marriage in New York Sta named above by any person authorized by New York Domestic
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 }
~
YEAR
MONTH
YEAR
NAME (PRINT)
TIME
MONTH
AM
M
2005
07
26 2005
05
28
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 1) vrr..~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .I;Yf6'"WN OF 0 VILLAGE OF II
SPECIFY LA G-n Pell\) 6-IW I _ e
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
CIVIL
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)