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COUNTY Dutchess
CITYfTOWN Wapt;inger
~~J~kc; 1368
~5~~J~R 96
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
'k!'~Py L PittnMUtNT SURNAME
J
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
~
L D SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. FULL NAME
11. A. FULL NAME
Reblg:a L La ~T SURNAME
FIRST
FIRST
B BIRTH NAME, IF DIFFERENT
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE n:&I.'men
(OPTIONAL - SEE REVERS~ '1&1
D. SOCIAL SECURITY NUMBER 090-66-9371
12. RESIDENCE A. N ~TATE) B. DattGhcss
C. ~~6CK ONE 0 CITY r;jj,t TOWN 0 VILLAGE
SPECIFY V'Jappinger
D. STREET ADDRESS 1 Henry Roed ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
Mt;aH /2t.Y _
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 05?-60-9359
2 RESIDENCE A. N Y B.
(STATE)
C. CHECK ONE 0 CITY 'W TOWN 0
AND Wa .
SPECIFY ppoger
o STREET ADDRESS 1 HenlY Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ti! NO
3 A. AGE 26 38 DATE OF BIRTH MoUI / U / 1&16
~.
VILLAGE
13. A. AGE 26
14. EMPLOYMENT
13.8 DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION L.a~piFlg
8 TYPE OF INDUSTRY OR BUSINESS SeIf-Ampoyed
5 PLACE OF BIRTH ~~~''N* York
6. FATHER
A. NAME Moses Lee Pittman
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME UndI . lean Rossbectl
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
A. USUAL OCCUPATION VVaiIress
B. TYPE OF INDUSTRY OR BUSINESS Red L.obster
15. PLACE OF BIRTH ~O'N" York
16. FATHER
A. NAME Gaetano Joseph LB Suse
B. COUNTRY OF BIRTHPal8FFAG. Sicily
17. MOTHER
A. MAIDEN NAME Claude Jen Selkow
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
1ST
2ND
3RD
o D
o D
D D
D D
pediment exists
D
D
D
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY 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.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by New York Domestic
~
{ } NAME (PRINT)
SEAL SIGNATU;;~
~tt.Ds
~ STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
MONTH
YEAR
YEAR
TIME
MONTH
AM
PM
7
25
2003
22 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. CO~~
ZIP
1~:
C. LOCATION OF CEREMONY
(CHECK ONE AND~IFY)
D CITY OF ~OWN OF D VILLAGE OF
t)ECIFY uJAP()/~
29. OFFICIANT
NAME (PRINT)
STREET CITY/TOWN
30 WITNESS TO CEREMONY
NAME (PRINT) . Gea", 9 ~~~dCV".
SIGNATURE~ ~~
DOH-98 (11/98)
WIT"" m o~
::::::~'. . ~~~