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COUNTY Dutchess
CITYITOWN Wappinger
~)ISTRICT 1388
NUMBER
REGISTER 88
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT,' LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Francis G. Bronzo, JR.
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tra~ M Penik
MIDDLE CURRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
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N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE 8rrJn2oo
D. sJg~I~~~Ri~E:U~~~~RSE) 093-68-7655
12. RESIDENCE A. ~ErOrk B. ~
C. CHECK ONE 0 CITY Ofljlf-OWN 0 VILLAGE
AND 'A_.
SPECIFY v~ppnger
D. STREET ADDRESS 30 Mac Intosh lane ZIP 125SK1
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE ~ 13.8. DATE OF BIRTH ~ . / ~7v /<1.
14. EMPLOYMENT
A USUAL OCCUPATION SyBt.erns AnatyBt
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
15. PLACE OF BIRTH ~ Plains", New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME William Paul Penik
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mlde Irene SoltysIak
B. COUNTRY OF BIRTH GermA"V
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
O. 0
C. SURNAME AFTER MARRIAGE
(OPTIONAl. SEE REVERSE) 05f"l1AD7D36
D. SDCIAL SECURITY NUMBER ~
2. RESIDENCE A. New Yark
(STATE)
C. CHECK ONE 0 CITY d'TOWN
~~CIFY Carmel
D. STREET ADDRESS 515 VIsta On The Lake
B. Putnam
(COUNTY)
o VILLAGE
ZIP 10512
o YES c1' NO
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
3. A AGE 46 38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Union Sheet Metal Worker
B. TYPE OF INDUSTRY OR BUSINESS Local 38
5. PLACE OF BIRTH Brooldvn- New York
(CITY~S;:;'~NTRY IF NOT USA)
6. FATHER
A. NAME Francis Gerard Bronza, Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Madeline T. PlellI
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 1
8. HOW DID LAST MARRIAGE END? (3) cfDIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08/ 04 / 1997
MONT':!J DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? []"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
1011811987 Carmel. New York
D6I04/1f1E11 White PIli... New York
DEATH
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DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH . DAY
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
YEAR
o
D'
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1ST
o 2ND
o 3RD
o 4TH
lief that the in~matlon I provided is true
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IGNATURE OF BRIDE.
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of the bride and groom named above by any person authorized
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
ZIP
AM
02:49PM
08
TIME
YEAR
MONTH
08I02l2004
Falls NY 12590
WN SA
27. TYP~ CEREMONY
o ~ELlGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B. COUN1:;j)U;ftfh;s.s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY O~ OJ TOV:N OF ~GE OF
SPECIFY VVAfJfJINGr;f2,S fA.u-s
TITLE
If. ~ fk'Gsr
1""/)'( /()~.
f .
NAME (PRINT)
SIGNATURE.
nnf..lAR (11/QA\