020
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STATE OF NEW YORK I STATE FILE NUMBER
] Dutchess (THIS SPACE FOR STATE USE ONL Y)
COUNTY DEPARTMENT OF HEALTH
CITYrrOWN Wappl'\g8I'
~~~~k1i ' 1368 AFFIDAVIT, LICENSE and j
~5~~J~R 20 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME .~ R RnrAUiII. 11. A. FULL NAME F'i7~hP-tb l< Nan~Hli
FIRST CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Sor-nlla
(OPTIONAL. SEE REVERSE) ......
D. SOCIAL SECURITY NUMBER 122-64-1128
12. RESIDENCEA. ~rodc B. ~esl
C. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND ''''_'
SPECIFY VVMpp'OgP-r
D. STREET ADDRESS ~ Sttlre)' lane !Vi A ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 23 13.B. DATE OF BIRTH MOW / ~
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH \~ ~ York
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16. FATHER
A. NAME Michael A. Mana ISi Sr:.
B. COUNTRY OF BIRTH U S fa.
17. MOTHER
A. MAIDEN NAME elizabeth lamlsoher
B. COUNTRY OF BIRTH U G A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 ~4407
2. RESIDENCEA. _IYorIf B.~
C. CHECK ONE 0 CITY Q,fIrOWN 0 VILLAGE
AND ,...r.-'
SPECIFY v_ppngP-r
D. STREET ADDRESS 25 $urrelV lan' f1+P A
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 24 3B. DATE OF BIRTH
4. EMPLOYMENT
12590
YES Mo
/1$IP
ZIP 12590
o YES cYNO
A. USUAL OCCUPATION CaIpel1ter
B. TYPE OF INDUSTRY OR BUSINESS Self - Empl~ed
5. PLACEOFBIRTH (~~X_
6. FATHER
A. NAME Michael Cbades So_lla
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Uracil Merl. Mays
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
DEATH
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(2) 0 DEATH
o
o
(2) 0 DEATH
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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
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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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
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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
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23. SUBSCRIBED AND SWOR TO
SIGNATURE OF TOWN 0 CLERK ~
This license authorizes the marriage in New York Stat of the
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 onl ose of a second or subsequent ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
York Domestic
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{ SEAL }
~
NAME (PRINT)
YEAR
MONTH YEAR
TIME
MONTH
01
05 30 2004
04
2B. PLACE WHERE MARRIAGE OCCUR~ _ '
A. STATE NEW YORK B. COUN~~' cf/1i
C. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
c.o(l.:r~n1~
NAME (PRINT) .
SIGNATURE ~ .