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038 I- Z W rn W III o ..J => o J: rn Z o ~ <( cr: t;; a W cr: W (!l <( a: cr: <( ::; u. o W !;( t) u:: ~ cr: W t) W cr: W J: ;: rn rn W cr: o o <( ,. u. (3 W "- rn ~~~ W 1-;:1- ~ ~~~ - I-WZ ..... 3dai 0 ~~g u:: z- G~~ i= [om a: 01-,. W w~C5 0 5~"' Z::::i~ COUNTY [)ut~~ CITY/TOWN WappinQAr ~lfJ~kc: 1 ~ ~Q~I~J~R ~ STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM ~9[)l ~ Muno2' MIDDLE CURRENT SURNAME I STATE FILE NUMBER (THIS SPACE FOR STA TE USE ONL Y) I L 0 SUPPLEMENTAL FILE FROM THE BRIDE Donna M Mele MIDDLE CURRENT SURNAME ~ 1. A. FULL NAME 11. A. FULL NAME FIRST FIRST 0- N B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT C. SURNAME AFTER MARRIAGE Mun02' (OPTIONAL - SEE REVERSE) 243-31 4724 D. SOCIAL SECURITY NUMBER ----- . --- 12 RESIDENCEA. N,MErork B. q'cf!~ess C. CHECK ONE 0 CITY 0 ~OWN 0 VILLAGE AND We' SPECIFY P$Jnger D. STREET ADDRESS 77 All Angels Hili Road B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER 132.54-23QO 2. RESIDENCE A. New V ork B. nl"l"h~ct ('S'!'M) ~ C. CHECK ONE 0 CITY o;rOWN 0 VILLAGE AND Wa' SPECIFY pp1nger D. STREET ADDRESS 77 All Angels Hili Road ZIP 12590 E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES ~NO 3. A. AGE 29 38. DATE OF BIRTH MO~ / Dl,p / Y'A~7 ZIP 12590 YES [JI NO AQ6~ YEAR E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 13. A. AGE 38 13.B. DATE OF BIRTH 11 / M MONTH DAY 14. EMPLOYMENT A. USUAL OCCUPATION Office Manager B: TYPE OF INDUSTRY OR BUSINESS Hannaford Bros. Co. 15. PLACE OF BIRTH Hartford Connecticut (CITY. STATElcoLNTRY IF NOT USA) 16. FATHER A. NAME Leo Mele B. COUNTRY OF BIRTH USA 17. MOTHER A. MAIDEN NAME Ther~ OnQlri B. COUNTRY OF BIRTH USA 18. NUMBER OF THIS MARRIAGE 3 4. EMPLOYMENT ~ :> < c "U:: u. < A. USUAL OCCUPATION Grocery Manager B. TYPE OF INDUSTRY OR BUSINESS Hannaford Bros. Co 5. PLACE OF BIRTH P~utth~ll!t New V ~rk (CITY, S~N5TU5A) 6. FATHER A. NAME steven I ance Mun02' B. COUNTRY OF BIRTH USA 7. MOTHER A. MAIDEN NAME Irene Caroline Grace Leckie B. COUNTRY OF BIRTH AMtIAnd 8. NUMBER OF THIS MARRIAGE 1 a: w III ::; :::> Z o Z 0( Iii w a: .... en 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT 2, 0 B. HOW DID LAST MAR~IAGE END? . (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 ~VORCE (3) 0 ANNULMENT (2) 0 DEATH C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 08/ 01 / 2001 . MONTH DAY YEAR MONTH DAY YEAR D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO . D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 lifts 0 NO 10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM (MONTH. DAY, YEAR) (CITY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE 1ST 0 0 1ST ~/1ggs Carm8l, NewVm 0'; 0 2ND 0 0 2ND 08101/.2001 poughkeepsie, New York 0 0'; 3RD 0 0 3RD 0 0 ~ 0 0 ~ 0 0 I, being duly sworn, depose and say, that to the best of my knowledge and belief t at the information I provided is tr ~nd that I declare t.at no legal impediment exists . SIGNATURE OF BRIDE ~~ .1./7\..,,,,,, In. I)~ USE CURRENT NAME' I - 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DEATH o DEATH o 23. ~~J.fT~~~DC:N~~~O;~ 6'fvB~~~i~E DATE 05J04J2004 This license authorizes the marriage in New York Stat of the person authorized by New York Domestic Relations Law !}11 to perform marriage ceremonies within w 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 w Cf) Z W o ::i 05 ~ { SEAL } '-v-' YEAR NAME (PRINT) SIGNATURE ~ MAILING AOD.RE TIME MONTH 11:38M PM ZIP STREET I CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF THE PER- SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND PLACE INDICATED. 28. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNrv1)u ,=h~~ C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF 0 TOWN OF 0( VILLAGE OF SPECIFY W a~ ~ e.~ i:o= \ \S T\ \ CIVil NAME (PRINT) SIGNATURE ~ nn~.QR /11IaR' ....