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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JfitpY M DunaENT SURNAME
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
y knowledge and belief that t e Information I provided is true and that I declare that no legal impediment exists
~~
21. ~ USE CURRENT NAME
23. DATE CflICflI2J.X)3
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE :VALID IN NEW YORK STATE ONLY.
o "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
COUNTY Dutchess
CITYITOWN Wappinger
~~J:~<;J 1368
~5~~J~R 87
1. A. FUll NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER Q95.4G.8507
2. RESIDENCE A. N (XATE) B. ~
C. CHECK ONE ill! CITY 0 TOWN 0 VILLAGE
~~~CIFY ~
D. STREET ADDRESS 24 Vall AVMUA ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~ YES 0 NO
M~ /~~ /1~9
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
3. A. AGE 54
4. EMPLOYMENT
A. USUAL OCCUPATION ('..a~
B. TYPE OF INDUSTRY OR BUSINESS Unton
5. PLACE OF BIRTH _m~FY~)
6. FATHER
A. NAME Stephen John DunAV
B. COUNTRY OF BIRTH II S A
3B. DATE OF BIRTH
7. MOTHER
A. MAIDEN NAME Loll M_ Me lA_n
B. COUNTRY OF BIRTH 1I SA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
~1~,.lo'!J
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Marianne E Chorba'
MIDDLE CURRENT SURNAME
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Bora
C. S~~~~JN~~~~~t~~e~~s~nay
D. SOCIAL SECURITY NUMBER Q64..36 ~459
12. RESIDENCE A. N 'tTATE) B. ~
C. CHECK ONE 0 CITY [jlITOWN 0 VILLAGE
AND 'AI- .
SPECIFY VVlllPP~
D. STREET ADDRESS 7 F.ranton DrIve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES r1J/ NO
~H /1~y ,{~
13. A. AGE '!iT
14. EMPLOYMENT
A. USUAL OCCUPATION T~ A_......nt
B. TYPE OF INDUSTRY OR BUSINESS vv.pp Cntrl
15. PLACE OF BIRTH '~~RX'vUSA)
16. FATHER
A. NAME \/ietnr ~~ Rnm
B. COUNTRY OF BIRTH USA
13.B. DATE OF BIRTH
SehM
001
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) [!I'DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 17 / 1QQt:t
MONTH QAY 1~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES I!I"'NO
10. 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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17. MOTHER
A. MAIDEN NAME Role M.ry lAmer
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED?
MONTH !2A
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES I!rNO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORM
DATE OF DECREE PLACE ISSUED AGAINST
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF
DEATH
1
(2) ~EATH
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{ SEAL }
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NAME (PRINT) TIME MONTH YEAR
AM 07
ZIP 03:06 PM
10 CIVIL
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