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COUNTY
~YfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Timothy G.
FIRST MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
Dutchess
Wappinger
1368
35
~
L D SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Susan L.
CURRENT SURNAME
Antalek
1. A. FULL NAME
Pagones
CURRENT SURNAME
FIRST
MIDDLE
0-
N
B. BIRTH NAME (MAIDEN NAMEI. IF DIFFERENT
C. SURNAME AFTER MARRIAGE Pagones
o S~~~~I~~t~R;T~E~U~~~~RSE) 082 -6 4-12 7 4
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE Xi CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
D. STREET ADDRESS 82 So. Chestnut StreetzlP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? jlg YES 0 NO
/25 /1966
DAY YEAR
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2 RESIDENCEA. New York 8. Dutchess
(ST A:{F) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
o STREET ADDRESS 82 So. Chestnut StreeJp 12508
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 00 YES 0 NO
/ 23 /1963
DAY YEAR
115-42-4632
38
13.B. DATE OF BIRTH
12
MONTH
3. A. AGE
42
O~
13. A. AGE
,38. DATE OF BIRTH
MONTH
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Antalek & Moore Ins.
15. PLACE OF BIRTH Beacon;-New York
(CITY, STATElCOUNTRY IF NOT USA)
UJ
~
>-
CIl
A. USUAL OCCUPATION Attorney
B. TYPE OF INDUSTRY OR BUSINESS Pagones & Cross
5. PLACE OF BIRTH Beacon, New York
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAME
8. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Lee Ann Papo
u. S. A.
2nd
6. FATHER
Frederick Neil Antalek
u. S. A.
A. NAME Anthony Louis Pagones
B. COUNTRY OF BIRTH U. S. A.
7. MOTHER
A MAIDEN NAME Felicia Spinapolice
B. COUNTRY OF BIRTH U. S. A.
2nd
18. NUMBER OF THIS MARRIAGE
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BV
DIVORCE CIVIL ANNULMENT
One
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? (3) 00 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3)Xi DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? March /25 /2003 C. DATE LAST MARRIAGE ENDED? 07 / 18 /2001
MON"T1;!. DAY YEAR MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO D. ARE ANV FORMER SPOUSE(S) ALIVE? Xl YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION 20. IF PREVIOUSL V 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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
3/25/2003 Poughkeepsie, NY W 0 1ST 7 /18/2001 Poughkeepsie. NY 0 ~
o 0 2ND 0 0
o 0 3RD 0 0
o UH 0 0
nd belief that the information I provided is true and that I declare that no leg I impediment exists
w
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21. ~. SIGNATURE.OF BRIDE ~...,J,
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 1111 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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) Gloria J. Morse
..,r.<" {)
SIGNATURt..... ,,?<::;'~VA.~'
MAILI~G ADDRESS
2u Middlebu
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
7
10
DATE
by New York Domestic
~
{ SEAL }
'-y-I
YEAR
MONTH
YEAR
TIME
MONTH
DATE 5/11/05
ers Falls NY
STATE ZIP
27. TYPE OF CEREMONY
~
3 : 25 PM
05
5
12
05
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D.t tc..k ~s:s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY -r-=s 'F'A-CdYt