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STATt: UF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Set!iliiatnck Q~SURNAME
COUNTY Drltches5
CITYfTOWN Wappinger
~~~fFi 1 '3613 .
~G~~~R 125
1. A. FULL NAME
FIRST
~. '" I'" rll",1;; 1~",...gS;;;"
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tam_Jean DeFl_~uRNAME
-.J
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 051-5"835
2. RESIDENCE A. N:J,. . B. ~88S
lATE)
C. CHECK ONE 0 CITY [illlTOWN 0 VILLAGE
AND W .
SPECIFY 8pp1nger
D. STREET ADDRESS 12 Central Ave01le
ZIP 12590
YES [il" NO
/~
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 36 3B. DATE OF BIRTH MJJl / 3A
4. EMPLOYMENT
A. USUAL OCCUPATION Salesman
B. TYPE OF INDUSmy OR BUSINESS I D Coh~n Ftll=nltllre
5. PLACE OF BIRTH ~~lIMMj'~
6. FATHER
A. NAME Terrence S Bowdetl
B. COUNmY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Roseman. SpiRa
B. COUNmY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID lAST MARRIAGE END? (3) cY'olVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? . 05 / na / 1 QQj'
MONTH OAr ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? o;tes 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
05lO9!1997 Dutchess Co.. New Yoit' 0
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11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE g,.... ....eA
(OPTIONAL. SEE REVERSE,......*-
D. SOCIAL SECURITY NUMBER 057 7 ~ 8993
12. RESIDENCE A. "J V B. no ...".......,.S
t"(5'I'ATE) ""'f~
C. CHECK ONE 0 CITY Q;rOWN 0 VILLAGE
~~CIFY \.^Jappinger
D. STREET ADDRESS 12 Central Avenue ZIP 125SK)
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 34 13.B. DATE OF BIRTH M01t / 2iy ~~
14. EMPLOYMENT
A. USUAL OCCUPATION Project MIiRager
B. TYPE OF INDUSTRY OR BUSINESS Kraft Foods
15. PLACE OF BIRTH ~~,~~Jltk
16. FATHER
A. NAME Joseph De Palma
B. COUNTRY OF BIRTIH USA
17. MOTHER
A. MAIDEN NAME CaFeliAe Rase Bleakter
B. COUNTRY OF BIRTH USA
18. NUMBER OF TIHIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
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
o 0
o 0
o 0
o 0
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23. SUBSCRIBED AND SWORN TO FORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 0 the 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 onl for the urpose of a second Dr subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
21. SIGNATURE OF GROOM'~
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{ SEAL }
'-v-'
NAME (PRINT)
DATE 09l?4l2O()d
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
09:03AM 09
IP PM
1~IVIL
2
11
23 2004
25
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 T WN OF rI VILLAGE OF
SPECIFY
ZIP
"...rn"'roOE~. _~_
NAME (PRINT) ~ ~
SIGNATURE ~