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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J~ John stBniscrewRki .R
FIRST MIDDLE CURRENT llURNAME
:s I A I ~ t"IL~ NUMtI~H
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYITOWN Watdnger
~5'~~c;;r 1368
~5~I~J~fl 29
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
HeI;r;t~udr.ey DwJmJJJ SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl- SEE REVERSE)
D. SDCIALSECURllYNUMBER 121-74-?51R
2. RESIDENCE A. New York B. nl"M~!I;'
(S'i'iiTE) (CO~
C. CHECKONE 0 CITY !YTOWN 0 VILLAGE
;~CIFY Fishkill
D. STREET ADDRESS 2 Flshklll Glen Drive AP-. 2 Eip 12524
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!fI NO
3. A. AGE i? 3B. DATE OF BIRTH MO~ / 3>> / ~2
4. EMPLOYMENT
A. USUAL OCCUPATION Sales Man~r
B. TYPE OF INDUSTRY OR BUSINESS Auto Zt)ne
5. PLACE OF BIRTH Mount 1(1ct!ft. N8W V mil
(CITY. STATEICOUNTRY',F NOT USA)
6. FATHER
A. NAME Joseph John staniK7P.WR.Iri, Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Adneru... Campon.
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~~~~JN~~~~t~~~g~SE)StaRiSZ&\..I8ki
D. SOCIAL SECURITY NUMBER Q63...7 4-87 47
1.2. RESIDENCE A. N~YoJ1c B ~1iI
C. CHECK ONE 0 CITY [J,lI'rOWN 0 VILLAGE
;~CIFY Fi,.hkill
D. STREET ADDRESS ? .fi~hlri" ~Ip.n nriVp. Apt
..
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 21 13.B. DATE OF BIRTH Mo\Z /22.-
14. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Best Buy
15. PLACE OF BIRTH f~'bchf.IX9l'riA)
16. FATHER
2lZIP 12524
YES ~ NO
-1~BJ
A. NAME Robert Fnlnk Dwirulll
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Teresa Mary Kaiser
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
o
o
o
(2) 0 DEATH
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
/ /
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
o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
dge and belief that the information I provided is true and that I declare that no legal impediment exists
~~ II. .
~ ~ ~ .Jl 1
. USE CURRENT NAME - \
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23. SUBSCRIBED AND SWORN T
SIGNATURE OF TOWN OR C DATE
This license authorizes the marriage in New York State authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pur ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE.
MAIUNG ADDRESS
YEAR
MONTH
YEAR
TIME
MONTH
ATE DS/.02I2OO5
11:32~~ 05
ZIP
AT
27. TYPE OF CEREMONY
o 0 REUGIOUS
9 0 OTHER, SPECIFY
CIVIL
07 01 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN"'&~TZ.J4tca
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY uJ Wt<',;.,k ~ "Fd.!
03
STREET
I CERTIFY THAT I SOUEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
OATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ~D C v~SI
I
SIGNATURE.