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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM . ...
Joshua T. SatanBlci
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWt:!. wappinger
DISTRICT 1368
NUMBER
REGISTER 103
NUMBER
" DUPLICATE "
1. A. FULL NAME
FIRST
(THIS SPACE FOR STATE USE ONL Y)
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
Ullamt. A Me NamaraRNAME
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) Q5O. ~ -'541
D. SOCIAL SECURITY NUMBER 'I";;'"
2. RESIDENCE A. New York B. OrantIA
(STATE) J ~
C. CHECK ONE_ . ~ CITY ~ TOWN 0 VilLAGE
AND NeWDUrwh
SPECIFY · WI'
D. STREET ADDRESS 33 stony Run Roed ZIP 12550
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? 0 YES ~ NO
3. A. AGE Z1 3B. DATE OF BIRTH ~H / 1~y / \!l6
4. EMPLOYMENT
A. USUAL OCCUPATION steam Filter
B. TYPE OF INDU~~:.~BUSINESS LocII21
5. PLACE OF BIRTH ~keepsI.. New York
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME Joseph Peter SaI:ansIci
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME LomIIne Yalandll Berard
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVerCE CIVIL AOULMENT
11. A. FULL NAME
FIRST
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE o.atanski
(OPTIONAL - SEE REVERS~
D. SOCIAL SECURITY NUMBER 1 CJ3.-.7 ~ ~062
12. RESIDENCE A. t-J.~ark B. 0..-
C. ~6CK ONE 0 CITY GilI'TOWN 0 VILLAGE
SPECIFY Newbufgb
D. STREET ADDRESS 33 stony Run Ro8ct ZIP 12550
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? 0 YES}I NO
13. A. AGE 25 13.B. DATE OF BIRTH & / ~Y lsYJR
14. EMPLOYMENT
A. USUAL OCCUPATION Teller Manager
B. TYPE OF INDUSTRY OR BUSINESS Elank or ,...., York
15. PLACE OF BIRTH~~~ NOT USA)
16. FATHER
A. NAMEUtdll e1nr M~ N8m8l1l
B. COUNTRY OF BIRTf-irel8Ad
17. MOTHER
A. MAIDEN NAME Mary HaRnon
B. COUNTRY OF BIRT~RIIIACI
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(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, STATEICOUNTRY, 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
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23. SUBSCRIBED AND SWORN T
SIGNATURE OF TOWN OR CI CLERK ~
This license authorizes the marriage in New York State 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.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CiC CI,.ER~ 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ana
TIME MONTH
SEAL SIGNATURE ~ DATD8lD1Q003
2&IMitIMiIIh Rd, Falls NY 12590
~ STREET ITYfTOWN TATE
I CERTIFY THAT I SOLEMNIZED N OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa~
as to my right to enter into the marri .
o
o
o
o
o
o
DATE
by New York Domestic
ZIP
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YEAR
02
2003
30 2003
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY L//~ !~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VilLAGE OF
SPECIFY f!1'{jlf ! 6 (.;.n
29. OFFICIANT -
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~