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STATE OF NEW YORK I STATE FILE NUMBER I
COUNTY [)~~ (THIS SPACE FOR STATE USE ONL Y)
CITYiTOWN Wappinger DEPARTMENT OF HEALTH
~~~~~~T 1368 AFFIDAVIT, LICENSE and
~5~I~J~R 2 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
A FUll NAME MattheYI Frank Buonato 11. A. FUll NAME Myra I eah Arri~
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE ARENT SURNAME
n.
N
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE RunnAtn
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ?Q.64..nn~7
12. RESIDENCE A N ';CTATE) B. ~
C. CHECK ONE 0 CITY [JI'TOWN 0 VILLAGE
AND Wa .
SPECIFY ppnger
D STREET ADDRESS 17 Marlorvllle Road ZIP 1~go
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rJ! NO
13. A. AGE 23 13.8. DATE OF BIRTH n4 /1\0 ,iaA4
~H -ll"AY -~A'R
8 BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 08l'lo ~ 3995
D SOCIAL SECURITY NUMBER or-u,,-
2 RESIDENCE A. N Y 8. [)utchess
(STATE) J (COUNTY)
C CHECK ONE 0 CITY 1!I TOWN 0 VlllJ.GE
AND p. .....kee .
SPECIFY OUWII PBle
D STREET ADDRESS 3 Mark Court ZIP 12603
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
11 /22 /1978
MONTH DAY YEAR
3 A AGE 26
38. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Registered NUrAe
B. TYPE OF INDUSTRY OR BUSINESS ~~Ar MMM (".ntJ
15. PLACE OF BIRTH Bronx New York
(CITY, ST:tTE/COUNTRY IF NOT USA)
16. FATHER
A NAME Salvador Arriaga, Jr
B. COUNTRY OF BIRTHU SA
17. MOTHER
A. MAIDEN NAME Mildred Nee
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
4. EMPLOYMENT
A USUAL OCCUPATION Corrections Officer
8. TYPE OF INDUSTRY OR BUSINESS Flshkill Corr. FacilItY
5. PLACE OF BIRTH Poughkeepsie. New Yark
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME James Joseph Buonato
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Dehorna Elizabeth Haberstroh
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
DEATH
DEATH
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE ENO? (3) 0 DIVORCE
C. DATE IJ.ST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 OEA TH
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
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
0:
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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
1ST 0 0
2ND 0 0
3RD 0 0
4TH 0
I, being duly SWDm, depose and say, that to the best of my knowledge and
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~
o 0
o 0
o 0
o 0
egal impediment exists
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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 by New York Domestic
Relations Law ~11 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 CLI~RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona J
TIME MONTH DAY YEAR MONTH DAY
SEAL SIGNATURE ~ " DATE 01J0312OO5
'-.,-I ~T~W(Be owfalls ~TA~2590 ZIP 02:53 ~~ 01 04 2005 03 04 2005
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY ~ 28. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER- fa
SONS NAMED ABOVE ON THE RELIGIOUS 1 CIVIL NEW YORK .,iT-e~
DATE AND AT THE TIME AND A. STATE B. COUNTY
PLACE INDICATED. OTHER, SPECIFY
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF rVVlLlAGE OF
SPECIFY /.IJ14(f1-;;;6~ ~
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
31.
NAME (PRINT) )I
SIGNATURE ~