041
STATE OF NEW YORK I STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dl.-tch". DEPARTMENT OF HEALTH
CITYfTOWN Wappinger
;?ISTRICT AFFIDAVIT, LICENSE and
NUMBER 1..
REGISTER 41 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FUU NAME MIBpbelt Psli'Br&E 11. A. FUU NAME MIDrNiBDft 8. Il~RNAME
FIRST FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
Q95 62 7G2
2. RESIOENCEA. ~..v........ B ~"'-'--
(STA'rI!l--- :J _11\ . (COUfWl'l....... .--
C. ~~fiCK ONE 0 CITY 0 TO~ 0 VILLAGE
SPECIFY t't'appiRg&r
D. STREET ADDRESS 8 Sc:otae Roacl ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO"
3. A. AGE "U:' 3B. DATE OF BIRTH L _L 1
~ MONTH ~ DAY Zti'" YEAR
4. EMPLOYMENIT
A. USUAL OCCUPATION ste&mfiler
B. TYPE OF INDUSTRY OR BUSINESS
l.eeel 21
5. PLACE OF BIA-~. (CITY, ~"""'INt/!.&.Y GFk
6. FATHER
A. NAME Robeft P8IidBre Sr.
B. COUNlTRY OF BIRTH
7. MOTHER
us,.
A. MAIDEN NAME
B. COUNlTRY OF BIRTH
Sharon Holle
USA
1
8. NUMBER OF nils MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENIT
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(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
o
o
o
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York
Relations Law ~11 to perform marriage ceremonies wit
o If checked, this license i
24. TOWN OR CITY CLERK
r-"-.
{ SEAL }
'-v-I
NAME (PRINT)
STAE T
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
O. SOCIAL SECURITY NUMBER
Palidorc
1Q5.64v9594
12. RESIDENCE A. ....... va..... B Duleh-
(ST~.. . --... . (COUNnl'~ -
C. ~5CK ONE 0 CIT~ 0 TOWN 0 VILLAGE
SPECIFY BBflBBR
D. STREET ADDRESS 3 SohGlllelcl Pleoe ZIP 12608
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE5.fJ NO
A. AGE 25 13.B. DATE OF BIRTH MONTH 08 DAY 2ff--vEA~!J7e
14. EMPLOYMENIT
A. USUAL OCCUPATION ReeftJit&r
B. TYPE OF INDUSTRY OR BUSINESS
Aeeotlntants Inc.
15. PLACE OF BIRTH (CITY,~.,.")N.....york
16. FATHER
A. NAME Marta" Mitchell P1..tt. ftif
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNtRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENIT
USA
Sherali ~ In Skelly
USA
1
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
~~H D~ 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
o
o
Domestic
TIME MONlTH
YEAR
YEAR
DATE
AM
27. TYPE OF CEREMONY
o ~IOUS 10 CIVIL
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-98 (11I9B)
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C.
R. c. r'~(~-r
t:r/ ~'v( (J ~
( 'h.t9 ~
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE