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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
N~. C. Uiefil"SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITY/TOWN Wappinger
, DISTRICT 1368
NUMBER
~5~~J~R 113
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M~le L C~SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
n.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER D91...s4-1D66
2. RESIDENCE A.-ItfM)Ycx:Ic B. ~m
C. CHECK ONE 0 CITY (JjfrOWN 0 VILLAGE
AND r>>.:1'..-
SPECIFY rJ.IIl.....awn
D. STREET ADDRESS 4:'1 J:SIJIt Mnunhlin AnIId
.t "
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE?
3. A. AGE as 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Test E~neer
B. TYPE OF INDUSTRY OR BUSINESS Cerdnal HNItb
5. PLACE OF BIRTH ~A~~Yodc
6. FATHER
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. S~S~~~'::~~~~~~~~SE)Laiadic:e
D. SOCIAL SECURITY NUMBER 100..ss..69S4
12. RESIDENCE A. NtMflalk B. ~
C. CHECK ONE 0 CITY o.,OWN 0 VILLAGE
AND 'AI.. .
SPECIFY Y_PP~
D. STREET ADDRESS 1782 Sotdb ROICI Lot 6
ZIP 10516
DYES ci' NO
13.B. DATE OF BIRTH
ZIP 1~
YES cYNO
1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
Mcir1 / Qj
13. A. AGE 31
14. EMPLOYMENT
A. USUAL OCCUPATION RecaJdI Coordnlltor
B. TYPE OF INDUSTRY OR BUSINESS N Y S ~ Of Correction!
15.PLACEOFBIRTH~1~ ~Yorlc
. USA
16. FATHER
A. NAME Peter ....mes C..isi
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME P8trIGlI Ann \Afllrd
,. ..
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
-to-
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A. NAME Nicbal_ Laiaclce
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Reglne SUprlRG\....4.
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
o
B. HOW 010 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
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATEICOUNTRY.IF NOT USA) SELF SPOUSE
o
(2) 0 DEATH
o
o
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
o
(2) 0 DEATH
YEAR
YEAR
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21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK II'-
This license authorizes the marriage in New York Stat
Relations Law ~ 11 to perform marriage ceremonies within
o If checked, this license is to
24. TOWN OR CITY CLERK
~
{ SEAL}
"-v-I
NAME (PRINT)
SIGNATURE ~ -
MAILING ADDRESS
TIME
MONTH
YEAR
11:~~
08
26
10 24 2003
R
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 ~
C. LOCATION OF CEREMONY
(CH~K ONE AND SPECIFY)
~ITY OF TOWN OF 0
29. OFFICIANT
NAME (PRINT)
SPECIFY
NAME (PRINT)
SIGNATURE ~