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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jo!mLI' BeviI8CQYINT SURNAME
COUNTY Dutm !If
CITYrrOWN Wappinger
~~J~~c~ 1368
~5~~J~R 65
1. A. FULL NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 087 -6G-9686
2. RESIDENCE A. N <'tATE) B. ~
C. CHECK ONE 0 CITY 'ii1 TOWN 0 VILLAGE
AND e uoohw.-i
SPECIFY 01 v-w~...-e
O. STREET ADDRESS 6 $b8ler R~ ZIP 1~
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MJR; / ~1 /1i75
3. A. AGE Zl
4. EMPLOYMENT
A. USUAL OCCUPATION Cement Meson
B. TYPE OF INDUSTRY OR BUSINESS ~e Industries
5. PLACE OF BIRTH 'Yc:~ ~Re;
6. FATHER
38. DATE OF BIRTH
A. NAME Frank MicbNI BeviJIICqI"
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Mafglret Ann RamillY
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
DEATH
o
(2) 0 DEATH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cbricdine Castell
'MIDDLE !t'RNT SURNAME
~
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11. A. FULL NAME
FIRST
8. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~~N~~~~~t~~e~~s~lacqull
O. SOCIAL SECURITY NUMBER Q85.68..8-QQ
12. RESIOENCEA. N ';iTATEI B.~
C. CHECK ONE 0 CITY [jI'TOWN 0 VILLAGE
AND \ AI.. .
SPECIFY yyappl\gP-"
D. STREET ADDRESS A ~--~ CArdA liP 12SM
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!/ NO
13. A. AGE 33 13.B. DATE OF BIRTH ~H /01Y l'sq.G
14. EMPLOYMENT
A. USUAL OCCUPATION Realtor
B. TYPE OF INDUSTRY OR BUSINESS CoI~1 BenlMr
15. PLACE OF BIRTH 'Yc:~m,- XRf!
16. FATHER
A NAME (',hAde- .Jotln ('.-tllllll.,no
B. COUNTRY OF BIRTH II S A
17. MOTHER
A. MAIDEN NAME Cia.. DI R~
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
II n
DEATH
n
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
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
o
o
o
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
t I d;CI~~ediment exists
USE CURRENT NAME
DATE ~
by New York Domestic
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23. SUBSCRIBED AND SWORN TO B
SIGNATURE OF TOWN OR CITY L
This license authorizes the rriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 to perlorm 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
21. SIGNATURE OF GROOM ~
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{ SEAL}
'-.-'
NAME (PRINT)
-
SIGNATURE
MAILING ADDRESS
TIME
MONTH
YEAR
AM
PM
06
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
ATE
27. TYPE OF CEREMONY
0)1 RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A STATE NEW YORK B COUNT;DtJ1Ct(~ (S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
.r; , ,
SPECIFY ~ AST r I .s H K j L L
SIGNATURE ~
rlLlNCHDDREI'P
. 0, O.)bX 't;2 cg
STREET
30. WITNESS TO CEREMONY
P.
H 0 PfllJ t"l...l. (\IJ.'~ (;.-r: Dt
CITYfTOWN
m" ~\ (~S
DATE <: 63
"N~., I ,-c;'33
STAT ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~