004
"-
N
f-
Z
W
m
w .
CD
o
...J
:0
o
I
m
Z
o
~
<(
a:
f-
m
t5
w
a:
w
C!J
<(
ii'
a:
<(
::;;
t!-
O
LU
f-
<(
()
u:
~
a:
w
()
w
a:
w
I
;:
m
m
w
a:
o
o
<(
>-
t!-
U
W
"-
m
z z
~ ~ W
~ ~ t-
f- Z <(
~ a1 ()
~ ~ li:
~ u. i=
~ 0 a:
~ ~ W
W 0 ()
I- "'
o
z ~
COUNTY Dutchess
CITYITOWf\j. Wappinger
.~~J~~crJ 1368
~5~I~J~R 4
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Scott L Venske
MIDDLE CURRENT SURNAME
I
:::t I A I C riLl: "'UM~n::n
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
-.J
1. A FULL NAME
FROM THE BRIDE
Maria Pittman
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT t.A~as
C. SURNAME AFTER MARRIAGE Pittman. Venske
D. Sci~I~~I~~t~R~T~~U~~~~RSE) 057.. 72-6893
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY DroI\'OWN 0 VILLAGE
AND Wa .
SPECIFY pp1nger
o STREET ADDRESS 29G Alpine Drtve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES aI NO
03 /25 ~QJ\5
MONTH DAY YEAR
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 10":l54 0810
D. SOCIAL SECURITY NUMBER J-.
2. RESIDENCE A. New York B Dulclless
(STATE) (COUNm
C. CHECK ONE 0 CITY 0 TOWN [)I"VILLAGE
~~~CIFY Wappingers Falls
o STREET ADDRESS 68 East Main street
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 4~ 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Electronic Technician
B. TYPE OF INDUSTRY OR BUSINESS Home DeDOt
5 PLACE OF BIRTH at Paul MlnnMOta .
(CITY. STATE/CC!.UNTRY IF NOT USA)
6. FATHER
A. NAME Vincent Herbert Versk.e
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kathleen Ann Stemaman
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
ZIP 12590
alYES 0 NO
13. A. AGE 4Q
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Un.. EmplQyed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Brazil
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Donimgog Jouque
B. COUNTRY OF BIRTH Brazil
17. MOTHER
A. MAIDEN NAME Ezabel Carlnnha
B. COUNTRY OF BIRTH Bre~1
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) D~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? m / ?8 / ?ODS
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DlIlI'Es 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
1ST 0 0 1ST 02/.261.2003 Poughkeepsi., Ny D~ 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare th 1 no legal impediment exists
as to my right to enter into the marri state.
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
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
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
w
UJ
Z
W
()
:J
23 ~~J,fT~~~DO~N-?O~";:;O~~ 6~Bg~~~~E DATE 01/14D005
This license authorizes the marriage in New York authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with 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
r-"-.
{ SEAL }
'-.,-I
YEAR
MONTH
YEAR
NAME (PRINT)
TIME
MONTH
AM
01 :28'M
15 2005
01
15
03
ZIP
1~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURR~_
A. STATE NEW YORK B. COUN~1kefl
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~ILLAGE OF -'/4-
SPECIFY uJA-PP f;c6 rvM f;~
SIGNATURE