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COUNTY Dutchess
,CITYfT9Wfi. wappinger
DISTAI~T 1~
NUMBER
REGISTER 1 ;:Sf
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Alexander Dariel Greig
CURRENT SURNAME
I
STATE FILE NUM8ER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tori Leona Belesky
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
MIDDLE
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECU~f'1UMBER
2. RESIDENCE A. B. Dutchess
(STATE) ", (COUNTY)
C. ~5CKONEWa~~ ~.o VilLAGE
D. :~:~~ADDRESS 5603 PrI. - Circle ZIP 12590
E. IS RESI~fE WITHIN liMITS OF CITY OR INCORPORATED V1~GE? { YES 0 984
3. A. AGE 3B. DATE OF BIRTH / 1 / 1
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION RellglOl8 VVorker
B. TYPE OF INDU~~Ea..-nsl net ALI5lrIIra
5. PLACE OF BIRTH . a .
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER Bruce AI --- J G-'
A NAME ex..tygt 0 ....g
B: COUNTRY OF BIRTH ~...
7. MOTHER
A. MAIDEN NAME Colleen Ann Gordon
B. COUNTRY OF BIRTH ~Ia
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1VOlfE CIVil AN~LMENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Greig
(OPTIONAl - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY .B. Dutchess
(STATE)J (COUNTY)
C. ~5CK'" a CITY 0~;S IT VilLAGE
SPECIFY PIIng81'S
D. STREET ADDRESS ~ PrIncess Circle ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VilLAGE? r! YES 0 NO
13. A. AGE 17 13.B. DATE OF BIRTH 09 /24 A98E
MONTH DAY YEAR
14. EMPLOYMENT
A. . USUAL OCCUPATION Not VVorIdng
B. TYPE OF INDU/iW ~J3~~Ss... __ __
15. PLACE OF BIRTH VV8mnywn. NeW Z881and
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Peter James Belesky
B. COUNTRY OF BIRTH NeW ze8lana
17. MOTHER
A. MAIDEN NAME Barbara Anne Moutr.
B. COUNTRY OF BIRTH New Ze8land
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
D(iH
DE1)H
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
MONTH DAY 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
a:
w
CD
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Z
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(Jl
1ST 0 1ST 0 0
2ND 0 2ND 0 0
3RD 0 3RD 0 0
4TH 0 4TH 0 0
I, being duly sworn, depose and say, that to the b belie that t e information I provided.is t~rue and that I declare that no le~al impediment exists
as to my right to enter into the marriage state. ~
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO BEFORE ME. ' USE CU E 101D312003
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of t e bride and groom named above by any person authorized by New York Domestic
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 C 25. A. SOLEMNIZATION PERIOD BEGINS
--
NAME (PRINT)
SIGNATURE'~
MA~
w
en
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o
::i
01:15~~ 10
.-'-.
{ SEAL }
'-..-'
TIME
MONTH
YEAR
101D312003
DATE
Onger Falls, NY 12590
STATE
27. TYPE OF CEREMONY
o IV1iELlGIOUS
9 0 OTHER, SPECIFY
ZIP
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
DUTCtlt-S
10 CIVIL
I ()~
29. OFFICIANT M /~.o tOw CD 0 (J AI . i L1 lll\
NAME (PRINT) IS: _ ~'1 t1 'I
SIGNATURE~ 1Y\~ /;L ~~
MAILI~DDD:;;. /~ k P
STREET
30. WITNESS TO CER
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
i:W"6TY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY p~
NAME (PRINT)
SIGNATURE~
DOH-98 (11/98)
TITLE
DATE
SIGNATURE~
Certificate of
Consent
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
County
District
Number
Register
Number
CityfTown
This is to certify
, who have hereto subscribed
name, do hereby consent that
(I, we)
(name of minor)
who is
and who is under the age of
years, shall be united in
(my or our son or ward)
marriage to
by any minister of the gospel or other person authorized by law to solemnize marriages.
Witness my hand this
day of
19
~.....................................................................
~.....-_...............................................................................
(Signatures of Parents or Guardians)
~.........................................................................................
(Signature of Issuing Clerk or a Notary Public)
This is to certify ItJ e , who have hereto subscribed
~I\j l-eo~we)~eJe6~
ou,"
(my, our)
name, do hereby consent that
(name of minor)
who is i()L...lr dCl.u~Lt e-.r and who is under the age of I '&
(my or our daughter or ward)
marriage to Jjj€..xO~Q..J" 'Da~ ~(' ~3
years, shall be united in
by any minister of the gospel or other person authorized by law to solemnize marriages.
Witness my hand this
J~
day of 0 c~tOt:e.r
(;2003
~..........................................................
DOH-2279 (4/88) p. 1 of 2
(OVER)
Date 3Rd October 2003
To whomever it may concern,
I Peter James Be1esky & Barbara Ann Belesky give our daughter Toni Leona Belesky
(Born 09/24/1986) permission to marry Alexander Daniel Greig.
Date of Signature (/D/ d. /0:>)
Date of Signature ( 10 / d / ~ )
Signature - Father Peter Belesky
Signature - Mother Barbara Belesky
r~_
~~
~ub-~C'_j\ ~ to ~ &AJO rY\
kx.fOr~ mL an ~ i~ anD ~ 06 OQ:tCber I 0f)0 -3.
QOfV\YY'\l5:S\ oy\ ' \('~s '. d..-~- {)i
~
No IFtrL.'i Public.
JAtMI L CIIIW\O
...., Public. State of .....
No. 01016086901_......
QuaI1tIed In DutCh... --..........
Cornmlllkm Expiree FebNWY -. ..,.,..