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00UMY Dutchess
CITYfTOWN Wappinger
~~J~~cJ 1388
~5~~J~R 64
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVI~UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.Inmllhan R Hnatb
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1. A. FUll NAME
11. A. FUll NAME
~ L 8cgnitRRENT SURNAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 049-68-?RQR
2. RESIDENCE A. GPr~~cut B. ~d
C. CHECK ONE D CITY [)I'TOWN D VILLAGE
~~~CIFY Manchester
D. STREET ADDRESS 103 SyceMore lane ~ C ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
3. A. AGE 25 3B. DATE OF BIRTH ~ /?>>
4. EMPLOYMENT
A. USUAL OCCUPATION J;lellAArr.h ~me
B. TYPE OF INDUSTRY OR BUSINESS T. I G R
5. PLACE OF BIRTH ~,ll~~~IPICld
6. FATHER
A. NAME Paul.kRP.ph I-InSlth
B. COUNTRY OFBIR~H USA
7. MOTHER
A. MAIDEN NAME Cerol FAlACeI SaR:
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~~~~\15Ni~~~~t~~e~~SE)HFHJIh
D. SOCIAL SECURITY NUMBER 112~
1.2. RESIDENCE A. C~GUt B. ~rd
c. X~6CK ONE. D CITY CVOWN D VILLAGE
SPECIFY Msnch8Ster
D. STREET ADDRESS 103 Sycamore Lane.'\pt. C ZIP 08040
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
Ma5 / 1& ~982
08040
YES [jl' NO
/W9
13. A. AGE 22
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. . USUAL OCCUPATION Un Employed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~",,*,_l...-... Y-ork
16. FATHER
A. NAME \^Alli8m ChaFles Segnit
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nanc,y Ellen Hoose
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
(2) D DEATH
o ' 0 0
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY,IF NOT USA) SELF SPOUSE
D D
D D
D D
D D
pedimllPt exists
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
D
D
D
D
D
D
w
en
z
w
()
::::i
23. SUBSCRIBED AND SWORN T EFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE ~
MAILING A~DRESS
MONTH
YEAR
YEAR
TIME
MONTH
'DATE 06I.23J2004
AM
09:51 PM 06
24
2004 08 22 2004
28. PLACE WHERE MARRIAGE OCCURRED
ZIP
I
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF o-:-trlLLAGE OF
SPECIFYCfJo/~~. f1
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
buJc.~
10 CIVIL
1J.:3u
-
29. OFFICIANT - 'e;, IV
NAME (PRINT) " ..
'"""ru" ~ ,jJ; U
M L1N ADORES
, ~
STREET
30. WITNESS TO CEREMONY
TITLE
DATE
NAME (PRINT)
SIGNATURE ~
SIGNATURE ~