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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thnmac. I J\l11Y'e5
MIDDLE CURRENT SURNAME
[)IJlI' 1ST
~ 2ND
o 3RD
o 4TH
belie that the information I provided is true a
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage 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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY DutchM.~
CITYITOWN Wappinger
~~J:~CJ 13S8
~~~I~J~R 17
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER n?7 -~-59QR
2. RESIDENCEA. ~SXTE) B. ~
C. CHECK ONE 0 CITY o;rOWN 0 VILLAGE
AND 'A'-'
SPECIFY v_pp1nger
D. STREET ADDRESS 200 Wdmer Road
ZIP 1~go
DYES of NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 61 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION R~rm gftlff MAmhAr
B. TYPE OF INDUSTRY OR BUSINESS Anvlk ("..n'1'
5. PLACE OF BIRTH NMN RAtifnr~ ~-"'4!IIMI~
(CITY, STA~NOT iTsAi
6. FATHER
A. NAME Arthur ~..IIP-tAno NllneA
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Pauline Frances Boomer
B. COUNTRY OF BIRTH [ , S A
8. NUMBER OF THIS MARRIAGE ~
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
200
B. HOW DID LAST MARRIAGE END? (3) 06IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? ()5/?t\ / 1QQ?
MONTH OAr yr;:,r;:--
D. ARE ANY FORMER SPOUSE(S) ALIVE? DolEs 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
1ST 07/1411915 Alameda Co.. Califomia 0
2ND ~1M? Trl\'. NWI ynrk 0
3RD 0
~H 0
I, being duly swom, depose and say, that to the best of my knowledge an
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM.~ .:7 it. ~
DEATH
W
en
z
W
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{ SEAL }
'-.,-I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
I
STATE. t'IL~ NUMDcn
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
JClIril.~. Alexa~*rNT SURNAME
~
11. A. FULL NAME
FIRST
II. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Lasko
C. S~S~~JN~r~~~t':e~~SE)AlexaRder - NURes
D. SOCIAL SECURITY NUMBER 13Q..34.0653
12. RESIDENCE A. N(S'tTE) B. ~R
C. CHECK ONE 0 CITY O....OWN 0 VILLAGE
AND Wa'
SPECIFY ppn~r
STREET ADDRESS 200 \MdlTt.,r Road
12590
YES o;NO
-"1~
13. A. AGE 59
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION SeIf-er.Pployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH f~,~~ Yonc
16. FATHER
A. NAME Peter John L ~Im
B. COUNTRY OF BIRTH [I S A
17. MOTHER
A. MAIDEN NAME Mary HeieR l\IkaGS
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
2
o
o
B. HOW DID LAST MARRIAGE END? (3) O~VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 18 /?nnt\
MONTH OA"l ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? O~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
Qa1.3Q11 ~7 P-Oughkeepsle, N Y
09I1Bf.2000 Dutchess Co., N Y
o
o
o
DATE 0311912004
by New York Domestic
25. II. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME MONTH DAY YEAR MONTH DAY YEAR
ZIP 10:41~~ 03 20 05 18 2004
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL A. STATE NEW YORK B. COUNTYYl/Y-e,;htS.f