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COUNlY ~
CITYfTOWN WApplno-
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I JMt~ E ~SURNAME
;:)1#0\ It: riLe nUMDcn
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FmQ88 J. MSfmmrr SURNAME
.J
1. A. FUll NAME
11. A. FUll NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SDCIALSECURITYNUMBER 051-12-4617
2. RESIDENCEA.~)Yodc B. -~_B
C. CHECK ONE 0 CITY D.fTOWN 0 VILLAGE
~~CIFY PO~9'~psie
D. STREET ADDRESS 2710 So. Itb Road Unit 3c ZIP
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT stubliek
C. SURNAME AFTER MARRIAGE ..SFaD"" S""'"'e
(OPTIONAL - SEE REVERSE) n.. zra' . .......
D. SOCIAL SECURITY NUMBER 122 24 8668
12. RESIDENCEA. ~Y9Fk B ~ess
C. ~~5CK ONE 0 CITY D."JOWN 0 VILLAGE
SPECIFY Wappinger
D. STREET ADDRESS 18 E .l\Ipln. 0Rve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~
Mc02 / Q1 ~m
12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
~ / aa / vta21
13. A. AGE 71
14. EMPLOYMENT
13.B. DATE OF BIRTH
3. A. AGE 62
4. EMPLOYMENT
^- USUAL OCCUPATION Retired
B. TYPE OF INDUSTRY OR BUSINESS
3B. DATE OF BIRTH
A. USUAL OCCUPATION Dental AsBistaRl
B. TYPE OF INDUSTRY OR BUSINESS Ors. Sobel & Or. Mehmcr
15. PLACE OF BIRTH ~uNtviNY_
16. FATHER
5. PLACE OF BIRTH -ifpg~JIIMoY.
6. FATHER
A. NAME Honsce Settle
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Delli rerron
B. COUNTRY OF BIRTH U S ,~
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME JBSeph 8ttJbliek
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME lor. Nowinski
B. COUNTRY OF BIRTH U G A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
001
B. HOW DID LAST UARIllAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) D.iIlEATH
C. DATE LAST MARRIAGE ENDED? MONTH 07/ DAQ7 / v1i9O
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES [iIIO
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
1 0 0
B. HOW DID LAST MARRIAGE END? (3) o..,tVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09 / C! / ~9
MONTH OAt I ....,
D. ARE ANY FORMER SPOUSE(S) ALIVE? D~S 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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o 1ST 0911711879 Mlneda, t..york
o 2ND
o 3RD
o 4TH
and belief that the information I provide
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1ST
2ND
3RD
4TH
I, being duly swom, depose an say, that to t e best of my know!
as to my right to enter into the~.' e state. A) ..1
c....' . I
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 New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the u ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
by New York Domestic
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{ SEAL }
'-..-I
DATE 04I1SJ2004
YEAR
YEAR
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
'TIME
MONTH
04 16
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0'OWN OF 0 VILLAGE OF
SPECIFYti1f-f\ ~ e(
ZI
S
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1~IL