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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~LEd G sta~ SURNAME
COUNTY' Dutchess
'CITY/TOWN Wappngef"
~~J~~ 1388
~G~~J~R 157
1. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 267.85-5705
2. RESIDENCE A. New York' B. Greene
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN [9' VILLAGE
AND P rt-
SPECIFY U Ing
D. STREET ADDRESS 5~ Joel ~n ROAd ZIP 12470
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? rJ' YES 0 NO
MOQg / Q>> / ~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
J
E.
3. A. AGE 40
4. EMPLOYMENT
A. USUAL OCCUPATION F'ngj~r
B. TYPE OF INDUSTRY OR BUSINESS I A M
5. PLACE OF BIRTH ~J7J~~
6. FATHER
A. NAME !-Iarry Martin ~anqlJi~
B. COUNTRY OF BIRTH USA
7. MOTHER
38. DATE OF BIRTH
A. MAIDEN NAME Kathleen Alice Moormln
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Jane M Monell
MIDDLE CURRENT SURNAME
~
001
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~EATH
C. DATE LAST MARRIAGE ENDED? 04 / ~ / ')M3
MONTH Dr ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES rY\Ilo
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
2ND
3RD
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT RI~r
c. SURNAME AFTER MARRIAGE gfanqllklt
(OPTIONAL. SEE REVERSE) 1...... rA ~~
D. SOCIAL SECURITY NUMBER _~~
12. RESIDENCEA. NewVork 8. Ukrter
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN [JIl'vILLAGE
~~~CIFY Wallkill
D. STREET ADDRESS 11 Rugar Ulne ZIP 12589
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 41 13.B. DATE OF BIRTH M~ / ~ ",~
14. EMPLOYMENT
A. USUAL OCCUPATION Pharmar.y Technirian
8. TYPE OF INDUSTRY OR BUSINESS PlA"A I T C Pharmaey
15. PLACE OF BIRTH ~m~I'I'lO~. York'
16. FATHER
A. NAME .1M" ChartP-R Rltglilr
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME KItherIne Marie Valentino
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
'DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) oofJ'VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08 / no / 'YIt'In
MONTH DV ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
08I0912OOO Ulster county, N...: York 0; 0'
o 0
o 0
o 0
and that I declare that no legal impediment exists
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23. ~~:~~~~DO~~~~~~ 6'ivBgf~i~E DATE 12J0212OD3
This license authorizes the marriage in New York named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi n 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
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21. SIGNATURE OF GROOM ~
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{ SEAL}
"-v-I
NAME (PRINT)
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
22. SIGNATURE OF BRIDE ~
TIME
MONTH
YEAR
MONTH
YEAR
TE 12/.O2l2OO3
ZIP
31 2004
12
03
01
ATE
27. TYPE OF CEREMONY
~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY:i:>(J~h"'$5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY . A J" iJf\, II( ~-e ir-
, V v VVrr /
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
ZI
31. WITNESS TO CEREMONY
NAME (PRINT) :J)tv\ \ { \ U l e f\-r-
SIGNATURE ~ r-})rA..f'\" q" \\.Q ~ ~ ~