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COUNTY Dutchnl
CITYfTOWN Wappinger
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REGISTER 107
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RabedcA Beauh"'I~E
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kill\tiWflsy A D~suRNAME
11. A. FULL NAME
FIRST
1. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~6N~~~~~~~~SE)BeIIutMImaiB
D. SOCIAL SECURITY NUMBER 1aa.-7.Q.<9496
12. RESIDENCEA. N.~BFk B. ~
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND
SPECIFY \NappiRger
D. STREET ADDRESS 1 8 PembrOke aMI. ZIP 12699
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VilLAGE? 0 YES q, NO
13. A. AGE 21 13.B. DATE OF BIRTH tAlI / 14 ~_
14. EMPLOYMENT
A. USUAL OCCUPATION SIll. BpeeillliBt
B. TYPE OF INDUSTRY OR BUSINESS La\-M.
15.PLACEOFBIRTH ~~F~)
16. FATHER
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER Q50..62~
2. RESIDENCE A'~fiark B. ~r-B
C. CHECK ONE 0 CITY Cil'TOWN 0 VILLAGE
AND \A.....
SPECIFY y-PPlQger
D. STREET ADDRESS 19 Ptmbrolot Circle ZIP 125iO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? 0 YES i:i' NO
MeW. / 26 / S8
3B. DATE OF BIRTH
3. A. AGE 25
4. EMPLOYMENT
A. USUAL OCCUPATION CaAeCliDRI Oftic:er
B. TYPE OF INDUSTRY OR BUSINESS Ashldll torr. Facility
5. PLACE OF BIRTH
6. FATHER
A. NAME RabeIt BeauhamaiB
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Susan C. Green
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
A. NAME Eugene OIMd Dubiel
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME IIIe Merla Russo
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
000
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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, STATElCOUNlTRY, IF NOT USA) SELF SPOUSE
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNlTRY, IF NOT USA) SELF SPOUSE
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23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CUERK ~ DATE
ThiS license authorizes the marriage in New York State above by any person authorized by New York
Relations Law ~11 to perform marriage ceremonies within N York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the urpose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
YEAI
Domesti
~
{ SEAL}
'-v-'
YEAR
MONTH
TIME
MONTH
DATE CJBIOIQOO3
09".22 AM
PM 08
10 07 2003
28. PLACE WHERE1"ARRIAGE OCCURRED
09
A
27. TYIE OF CEREMONY
o Ii1" RELIGIOUS
9 0 OTHER, SPECIFY
1 0 CIVIL
A. STATE NEW YORK B. COUNTY QIIIe.,)>
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
JCITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY I../t? CJY'
29. OFFICIANT
NAME (PRINT)
R. C. . PA-5~ (i!J.
q/ Ir~3
TITLE
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) ~ .A . 13ellll"t"J.'l.(f~ ,~
SIGNATuRE~.5-Q.AA1Jl'" ~ ~
DOH-98 (11198)
NAME (PRINT)
SIGNATURE ~