027
23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State authorized
Relations Law ~11 to perform marriage ceremonies within Ne Drk 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.
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'-v-I MAI~ Mm~bush RdtWapp,.ger Falls, NY 12590 01 :1~~ 04
STREET CITYITOWN STATE ZIP
~~~R~~~Ri~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. OAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED.
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Anthony Rocco Di Mase
Dutchess
COUNTY W ppI
it n r
CITYfTOWr:6 5JC'
DISTRICT .,3S8
NUMBER "Z7
REGISTER .
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 085-76-6853
D. SOCIAL SECUIlIJY NUM!I~R
2 RESIDENCE A. New york B. Dutchess
(STATE)'; (COUNTY)
C. CHECK ONEWa 0 .CITY 0 TOWN 0 VILLAGE
~~~CIFY pplnger
D STREET ADDRESS 1 Spring Hili Court
12590
.,
YES 0 1:JQ._
/1~
YEAR
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED "MGE? ~
AGE 18 3B. DATE OF BIRTH /
MONTH DAY
3. A.
4. EMPLOYMENT
A. USUAL OCCUPATION Crew Chief
B. TYPE OF INDUs;J;flY OR l!lJ!.?INESS U. S. Air Force
5. PLACE OF BIRTH ...ougnKeepsle, New '(011<
(CITY, ST A TElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Rocco John Di Mase
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Leona Mae Nemeth
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOffE CIVIL AN1jLMENT
DEA~
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
o
o
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en
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(.)
::::i
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Martha Dolores Barragan
-1
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
8. .BIRTH NAME (MAIDEN NAME), IF BiU.
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) ::J~1-2:>-'::J( f
D. SOCIAL SECll.RJTY NU'4IliR
12. RESIDENCE A. New york B. Dutchess
(STATE)'; (COUNTY)
C. CHECK ONli.. _!:!: CITY 0 TOWN 0 VILLAGE
AND wappinger
SPECIFY 1 S In Hili Court
D. STREET ADDRESS pi' g
t2~
.,
Y~~
YEAR
ZIP
E. IS RESI~~CE WITHIN LIMITS OF CITY OR INCORPORATED ~GE? R
13. A. AGE 13.B. DATE OF BIRTH /1
MONTH DAY
14. EMPLOYMENT
Full lime student
A. USUAL OCCUPATION M nt St. M Coil
B. TYPE OF INDUs;J;fl1P.R BUSINESS ou ery ege
15. PLACE OF BIRTH ......acueran, Mexico
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER U
A. NAME nknown
B. COUNTRY OF BIRTH Unknown
17. MOTHER
A. MAIDEN NAME Marthe Berragan
B. COUNTRY OF BIRTH Mexico
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~CE CIVIL AN1jLMENT
DEA~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
o
o
1ST
2ND
3RD
o
o
o
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou~unlh:JlA
C. LOCATION OF CEREMONY
(CHECK ONE ANDJPECIFY)
o CITY OF tylOWN OF 0 VILLAGE OF
SPECIFY (J. )HP/~ 1.1\.
NAME (PRINT)
SIGNATURE ~