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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
TnniA N Pan On
MIDDLE ~RENT SURNAME
COUN1Y Dutchess
CITYIfOWN Wappl~
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1. A FUU NAME
FIRST
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B. BlRlH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURnY NUMBER 280-54-5384
2. RESIDENCE A .,York B. ~
C. CHECK ONE 0 CITY OII'rOWN 0 VILLAGE
AND .........
SPECIFY v~~
D. STREET ADDRESS 1.1 CAI'I"!'tAl HfIIg~
E. IS RESIDENCE WITHIN UMITS OF CIlY OR INCORPORATED VIlLAGE?
3. A. AGE 54 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Gener:81 Contractor
B. TYPE OF INDUSTRY OR BUSINESS Self - Employed
5. PLACE OF BIRTH --t#~~USA)
6. FATHER
ZIP 12590
DYES cVNO
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A. NAME Nikolaoe Penagiatakis
B. COUNTRY OF BIRTH Greece
7. MOTHER
A. MAIDEN NAME Marla XulxFldok
B. COUNTRY OF BIRTH G~
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) OlIlIVORCE (3) 0 ANNULMENT (2) 0 pEATH
C. DATE LAST.MARRIAGE ENDED? ()4/ 10 / ..caan
MONTH DAY Y'-
D. ARE ANY FORMER SPOUSE(S) ALIVE? DIIlfl:S 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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~~ryJ I ~tENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRiAGE PaftSlria
(OPTIONAL - SEE REVERSE) ..-..-zr
D. SOCIAL SECURITY NUMBER 293-64-8978
12. RESIDENCEA~E7fadc B. ~eIIII
C. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND Wa 0
SPECIFY PP"f)P-f
D. STREET ADDRESS l' Cannel HeIghts ZIP
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPOFlATED VILLAGE? 0
13. A. AGE 39 13.B. DATE OF BIRTHMoPa / ~
14. EMPLOYMENT
A. USUAL OCCUPATION Secl:etary
B. TYPE OF INDUSTRY OR BUSiNESS Nap Construction
15. PLACE OF BIRTH -ln9.l!~fp ~ York
16. FATHER
A. NAME Douglas F Aceblll
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Thelma JohASOR
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
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
12590
YES~
/1.
DEATH
o
(2) 0 DEAlH
(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
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1ST 0411011_ OM.. OhIo
2ND
3RD
4TH
I, being duly sworn, depoSB and say,
as to my right to enter into the marri e S
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CITY CLERK DATE
This license authorizes the marriage in New ork authorized by New York Domestic
Relations Law ~11to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
"-.t-I
NAME (PRINT)
22. SIGNATURE OF BRIDE ~
TIME
MONTH
YEAR
MONTH
YEAR
04
27
os
25 2004
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
r
27. TYPE OF CEREMONY
O~IOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNrY-eJr.JTt/...Uf
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Lk"fOWN OF 0 VILLAGE OF
SPECIFYW AflhJJ:1R
SIGNATURE~