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COUNTY ~
CITYfTOWN Wappinger
,~~~:kCRT 1368
~5~~J~R 142
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
nnnAld hi Pritr.hP.tt
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.JP..WAI SerrAno
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT C'..nIlirm
C. SURNAME AFTER MARRIAGE PritfflE!tt
(OPTIONAL - SEE REVERSE) "JI t 1'Y\.14n..
D. SOCIAL SECURITY NUMBER ~~--~~
12. RESIDENCE A. Nf!W V ork B. nlJt,...,~
ts'i'ATE) (couNrti
C. CHECK ONE 0 CITY 0 IIfOWN 0 VILLAGE
AND 'A'_.
SPECIFY vVBlppnger
D. STREET ADDRESS 212 RIver Road North ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D""NO
13. A. AGE 43 13.B. DATE OF BIRTH MOQV / ~ /1~1
14. EMPLOYMENT
A. USUAL OCCUPATION School RI. Driver
B. TYPE OF INDUSTRY OR BUSINESS A & E Tran$pOltation
15. PLACE OF BIRTH (Qf~.MIJN~n~etJt
16. FATHER
A. NAME Sentf!!ll C'..nIlirs
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Ethel Lol..e Bamhlll
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) An7 Jln ""t..t
o SOCIAL SECURITY NUMBER !!l:L~~~~~
2. RESIDENCE A. Np.w Vork B n. Jt~
(STATE) . ~-----
C. CHECK ONE 0 CITY c::Jof'rOWN 0 VILLAGE
AND
SPECIFY Wappinger
D. STREET ADDRESS 212 River Road North
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 50 3B. DATE OF BIRTH
ZIP 125M
DYES Of"NO
M
4. EMPLOYMENT
A. USUAL OCCUPATION Metro North Track' Worker
B. TYPE OF INDUSTRY OR BUSINESS !\AMrO North
5. PLACE OF BIRTH (~~Ry ~mr, \/iI:c;nla
6. FATHER
A. NAME .JAmf!!R I ynnnd Pritmett
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Eula 'Niltel'
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) [1II!\IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? ()8/ no / ')M.4
MONTH DA~ ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? DllfEs 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 08I09I2CJ04 Poughkeepsie, NewYor.k 0
2ND 0
3RD 0
1 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 liIJIvORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05/ 14 / 1C1O'7
MONTH DA'! ~r-o-
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 llIIt=s 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 0511-411997 Danbury, Conn.
2ND
3RD
o D-r
o 0
o 0
o 0
o legal impediment exists
w
en
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o
:::::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State
Relations Law ~11 to perform marriage ceremonies within N 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
DATE 11/?4nnn4
by New York Domestic
~
{ SEAL }
"-y-I
NAME (PRINT)
YEAR
MONTH YEAR
TIME
MONTH
10:3~~
25
01 23 2005
11
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTyDv+c..~'C:.s::;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF At TOWN OF 0 VILLAGE OF
SPECIFYWaW l^~ €<
TO CEREMONY
::::::: vr:~ c( ~~
DOH-9B (11/98)