025
I-
Z
W
'"
W
lD
o
...J
::J
o
:I:
'"
Z
o
1=
0(
a:
I-
'"
a
w
a:
w
CJ
0(
it
a:
0(
::;;
u.
o
w
!o:
()
u:
1=
a:
w
()
w
a:
w
:I:
;;:
'"
'"
w
a:
o
o
0(
>-
u.
(3
W
0-
'"
z Z
~ g W
ll! ;:5 l-
I- Z <C
gj ~ 0
~ g u:
~ u. i=
~ 0 a:
ts ~ W
Iii 0 0
b on
z ~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Fr~n.~ It E~JaR~URNAME
COUNTY Dutch~
CITYITOWN Wappingp.J'
S~J:~~T 13SA
~5~~J~R 25
1. A. FULL NAME
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SDCIAL SECURITY NUMBER
2. RESIDENCE A. I\IV
. ~tATE)
C. CHECK ONE 0 CITY O,.ltOWN 0 VILLAGE
AND
SPECIFY Np.w \Nincktnr
D STREET ADDRESS ~51 .IAcl<!;On Av~nue
ZIP
12553
11s..64-3979
B. IgS'~ge
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
o YES DlNo
3B. DATE OF BIRTH
I-
3 A. AGE 27
4. EMPLOYMENT
A. USUAL OCCUPATION Ins1Itar.u::e' ~m
B. TYPE OF INDUSTRY OR BUSINESS AllstD Ins.
5. PLACE OF BIRTH (~qq~~M,XQfk
6. FATHER
A. NAME Ftancis M Evangelista
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Lucilla M. Cana
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
-I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~ A Ilolle',c'"m- SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE E..s..........I.......
(OPTIONAL - SEE REVERSE) .. I 'l!I'" Q&CiI
D. SOCIAL SECURITY NUMBER 11 S-7G-5344
12. RESIDENCE A. ~~TE) B. Q_ess
C. ~~5CK ONE 0 CITY 0 ,jIJWN 0 VILLAGE
SPECIFY '.^Jappinger
D. STREET ADDRESS 5_Fr-aRton DFive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0""0
13. A. AGE 26 13.B. DATE OF BIRTH Mo84 / ia6 /1a~
14. EMPLOYMENT
A. USUAL OCCUPATION Office MaRager
B. TYPE OF INDUSTRY OR BUSINESS Chazen Ca's.
15. PLACE OF BIRTH (~~L~_Ij{fiA)
16. FATHER
A. NAME James AlexaRder HoIlersn
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Gloria Theresa Pedatella
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
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
MONTH OA Y 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
1ST
2ND
3RD
4TH
I, being duly sworn, depDse and say
as tD my right to enter into the marr'
21. SIGNATURE OF GROOM ~
o 1ST 0 0
o 2ND 0 0
o 3RD 0 0
o 0 4TH 0 0
nowledge and belief that the information I provided is true and that 1 declare that no legal Impediment eXists
22. IGNATURE OF BRIDE ~ '(}~\..QJ\.Ji ^ l\}-^-"(), 'dRQO · n A /1,,_
. USE CURRENT NAME -^db ~ -
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriag by any person authorized by New York Domestic
Relations Law ~11 to perform marriag ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o if checked, this license is to be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
w
rn
z
w
o
::::i
r-^-,
{ SEAL }
'-..-'
TIME
MONTH
YEAR
MONTH
YEAR
DATE
IP
08:~~
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMEO ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
, ATE
27. TYPE OF CEREMONY
O~GIOUS
9 0 OTHER, SPECIFY
10 CIVIL
08 06 06 2004
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW ;ORK. B. COUNTY V"" r...j, (~
TITLE
SIGNATURE ~
DOH-9S (11I9B)
04
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY A/e V b 1A..~' 4
jJ( if/(!)I
t/ ,.. 2~'" J f
/ 2. ..) ,J-O
STATE