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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Phillip Benjamin Dvorkin
Dutchess
COUNTY Wa
CITYITOW!;/~ ppmger
DISTRICT 1
NUMBER
REGISTER 148
NUMBER
1. A FULL NAME
FIRST
CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
MIDDLE
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 592-60-6704
D SOCIAL SEC~T~ JJUMBER
2 RESIDENCE A Y B Dutchess
(STATE) ., (COUNTY)
C CHECK ONWa D. CITY 0 JrlliVt-L 0 VILLAGE
~~~CIFY pplngers r-811S
D STREET ADDRESS ~O Delavergne Avenue, AJl;IP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? r5 YES 0 NO
3. A AGE 23 38 DATE OF BIRTH 01 /11 /1981
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Administrative Assistant
5. :~A:Y:~~:I:~UJl~eiY,:'~;anla
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER .
A. NAME irWin Dvorkin
8 COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Elaine Smith
8 COUNTRY OF BIRTH England
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV'l5CE CIVIL AN~LMENT
DEt)H
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Deborah Dinorah Clark
11 A FULL NAME
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Clark
C. SURNAME AFTER MARRIAGE Dvorkin
(OPTIONAL. SEE REVERSE) 051-64-1393
D. SDCIAL SECURITY NUMBER
12. RESIDENCE ANY B Dutchess
(STATE) ..; (COUNTY)
C. CHECK ONE Q CITY 0 TOWN LJ VILLAGE
~~~CIFY Wapplngers Falls
D STREET ADDRESS 1U lJeIavergne Avenue, Apt. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A AGE 31 13.B. DATE OF BIRTH 11 /16 .t973
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Sales Assistant
8 TYPE OF INDUSTRY OR BUSINESS Yellow Book, USA
15. PLACE OF BIRTH Manhattan, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAME Carlos Angel Clark
8 COUNTRY OF BIRTH Dominican Republic
17. MOTHER
A MAIDEN NAME Dinorah Miguelina Perez
8 COUNTRY OF BIRTH Dominican RepubliC
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI~RCE CIVIL ANj)ULMENT
DEATH
o
8 HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
8 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
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
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my knowledge and belief that the information I provided is tru
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23. SUBSCRIBED AND SWORN TO B RE ME
SIGNATURE OF TOWN OR CITY RK ~
This license authorizes the marriage in New York State of he bride and groom named above by any person authorized
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 C~I~.rK J M 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) 8.
TIME MONTH DAY YEAR
SEAL SIGNATURE ~
'- -.J M2a<Mmaxsh 08:53 AM 12
-v-- PM
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
21. SIGNATURE OF GROOM ~
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DATE
12/22/2004
by New York Domestic
MONTH
YEAR
23
2004 02
20 2005
1~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTy~L{1GIIti
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF 0 TOWN OF trVILLA~~F II
SPECIFY fA)~~~
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) T ~ ~
SIGNATURE ~ ~. "1