127
t"')'"
....
t"')'"
....
~"'
N
...-i
>-
....Z I-
m~ :>
~O .,
<DO'" .....
C1+J C
-'UW-
5~Clu..
ili ;:l ~ u..
zlJ ;; c(
o z
~....-I ~
a:....-I t:
~(l)~
a::CU
~(j)
~o
~::c
a:
.. "
::!;"Cl
15ctl
wO
~o:::
<.)
!!;(j)
t-
ffi"Cl
<.)0'"
~o:::
w a:
r,.:.: '"
~ctl~
~o ~
a: "
~~ ~
>-N ttl
u. a:
8 ~
a.
rn
z Z
~ ~ W
~ ~ l-
t- Z c(
'!J a5 U
~ ~ u:::
~ u. i=
~ 0 a:
b ~ w
w CI U
I- '"
o
z ;;::
COUNTY ~
CITYfTOWN Wapolnger
~~~~kc~ 1368
~5~~J~R 127
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
SmIt n AhrArmt.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
;/;1~~19'
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
TIWi, A Fabuq:ARENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
Q.
N
B. .BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~~~~~JN~~~~t~~e~~s~ms
D. SOCIAL SECURITY NUMBER 1Q6.-.74 5411
12. RESIDENCEA. N'(STATE) B. ~~ss
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY East FlShkill
D. STREET AOOREss289 Oak Ridge Road ZIP 12633
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES oWi! NO
13. A. AGE 28 13.B. DATE OF BIRTH ~H / EJlAY i97~
14. EMPLOYMENT
A. USUAL OCCUPATION Nunling
B. TYPE OF INDUSTRY OR BUSINESS Lovely Hills Nul5lng Heme
15. PLACEOFBIRTH~"'T~!MX.USA)
16. FATHER
A. NAME.lames Fabucci
B. COUNTRY OF BIRTt9ueIto Rico
17. MOTHER
A. MAIDEN NAME Anc::Iree Bust
B. COUNTRY OF BIRT_
18. 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) 11 n ~A A245
D. SOCIAL SECURITY NUMBER - - ~~-
2. RESIDENCE A. NY B. ~r-
C. CHECK ONE (STAO) CITY r!! TOWN 0 VILLAGE ( U Y)
~~~CIFY East FlShkill
o STREET ADDRESS 289 Oak Ridge R08d ZIP 1~
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES t'! NO
3. A. AGE 33 3B. DATE OF BIRTH M~ / Q,?y / t~10
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Slee.py's
5. PLACE OF BIRTH Bronx. New Y ark
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Carl Abrams
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Trudy Canadla
B. COUNTRY OF BIRTH Cuba
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
DEATH
o
(2) 0 DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
o 0
o D
o 0
o 0
I impediment exists
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
1ST
2ND
3RD
o
o
o
o
o
o
21 SIGNATURE OF GROOM ~
DATE 09I16f.2003
by New York Domestic
w
U)
Z
W
U
::J
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat 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.
D If checked, this license is to be used only for the purpose of a second Dr subsequent ceremony.
~ 24 TOWN OR CID CL.ERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) (:jfon8 J. Morse
{ () TIME MONTH YEAR
SEAL SIGNATURE ~
'- .-J ~1lfj AM
-v- STREET ZIP 1:46 PM 17 2003
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
1
15 2003
MONTH
YEAR
29 OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~,D..,(1C fIr;-s.$
10 CIVIL
flc. P IZ.I G?i
TITLE
DATE 5G-r(.)... 0, 'z"'CJc3
l) C .L?(.'<?
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF D. TOWN OF ~LLA~OF
SPECIFY UI 11-PP, '" GGf<..S rt1iL$
SIGNATURE ~
MAILING ADDRESS
.1700 0"""..... l~.;
STREET
30. WITNESS TO C
STATE
31. WITNESS
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~