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COUNTY Dutchess
CITYITOWN \NIDDlnger
~~fFi 1388
~5~~J~R fIT
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MichMI W l..aoa
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. ~Ull NAME
11. A. FULLNAME FIRST ISIfr c. B~URRENTSURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~SN~oi.A~~~~~~s~
D. SOCIAL SECURITY NUMBER 1Z. 70..5385
.12. RESIDENCE A. N '(TATE) B. ~~II
C. CHECK ONE 0 CITY liI' TOWN 0 VILLAGE
AND lA.. .
SPECIFY .....ppnger
D. STREETADDRESs110Cbetl. Cey ZIP 12580
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tIl NO
13.A. AGE24 13.B. DATE OF BIRTH ~ /OfAY _
14. EMPLOYMENT
.A. USUAL OCCUPATION CMb VVnIp Speci8l1st
B. TYPE OF INDUSTRY OR BUSINESS Gap
15. PLACEOFBIRTH~X.
16. FATHER
A. NAME'ftIom8s FnmcIs at... Jr
B. COUNTRY OF BIRT~ I SA. -
17. MOTHER
A. MAIDEN NAME S8I1V Jane 8oIoa1a
B. COUNTRY OF BIRn-U SA
16. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
ARST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl- SEE REVERSE)ftftD ~,. "W73
D. SOCIAL SECURITY NUMBER ~L ·
2. RESIDENCE A. N ;lATE) B. ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFY E8Bt Flshldll
D. STREET ADDRESS 23 TeconIc DrIve ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE22 3B. DATE OF BIRTH~
4. EMPLOYMENT
A. USUAL OCCUPATION Coale
B. TYPE OF INDUSTRY OR BUSINESS BnlnIDn \Naad!I Gal Club
5. PLACE OF ilRTH ~_Vcl1C' ... . ... .
6. FATHER
A. NAME WIi8m August l...aas
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAlDEN NAME PatrIdA Ann AH.ta
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
o 0
o
(2) 0 DEATH
DEATH
DEATH
o
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 (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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
YEAR
YEAR
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, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
IS true an t at are that no l!lga Impediment exists
22. SIGNATURE OF BRIDE ~ ~ c.. t2... ~ ,~ . .J...
# . USECURRENT~
DATE 07QAQ003
This license authorizes the marriage in N W York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage cerem ies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the U se of a second or subse uent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) J
TIME YEAR MONTH
~~ D5~ AM
-v- :15 PM
o
o
o
YEAR
22 2003
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 0 TOWN OF 0 VILLAGE OF
SPECIFY 'V(j~;f..
l~VIL
NAME (PRINT)
SIGNATURE ~
DOH-911 (11198)
NAME (PRINT)
SIGNATURE ~