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COUNTY DutehesE
CITYfTOWN \Afepplnger:
DISTRICT . ยท
~~~I~~~R 1368
NUMBER 43
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Peter ,g-Jistepher ~~NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
~ne M~ENTSURNAME
~
1. A. FUll NAME
11. A. FULL NAME
ARST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl- SEE REVERSE)
D. SOCIAL SECURITY NUMBER 0Ba.-7.()..8148
2. RESIDENCEA. "IV 8. .........._L___
n(!lIfATE) ~
C. ~~I5CK ONE 0 CITY ~ TOWN 0 VILLAGE
SPECIFY 'IJappinger
D. STREET ADDRESS SF Alpine o.we ZIP 12580
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORAlED VIUAGE? 0 YES 'iI NO
~/,];/W72
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE '-!~leIta
(OPTIONAL - SEE REVERS~
D. SOCIAL SECURITY NUMBER Q58 ii 03B7
12. ~ESIDENCE A. N YTATE) B. ~
C. ~~I5CK ONE 0 CITY ~TOWN 0 VILLAGE
SPECIFY \Happinger
D. STREET ADDRESS SF_Alpine DAve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORAlED VIUAGE? 0 YES fi1 NO
Jt1H /1~y ",_
3. A. AGE 30
4. EMPLOYMENT
3B. DATE OF BIRTH
13. A. AGE 23
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION St8te Treaper
B. TYPE OF INDUSTRY OR BUSINESS Ne\.v V_ state
5. PLACE OF BIRTH ~_.tlt~ V_
6. fATHER
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Dutch..1 Comm. Callege
15. PLACE OF BIRTH t,I,.,~~oY_
16. FATHER
A. NAME RBbeFt GelIe1t8
B. COUNTRY OF BIRTH US!,
7. MOTHER
A. MAIDEN NAME Duene Lake
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
A. NAME FFBnlclin David Mek8eI
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Christine Merle Trapasso
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 0 0
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 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
1ST
2ND
3RD
D
D
o
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
o
o
o
21. SIGNATURE OF GROOM ..
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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 perfomvmarriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
" 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 0411712003
by New York Domestic
,-I'-..
{ } NAME (PRINT)
SEAL SIGNATURE ..
MAILING ADORES
~
TIME
MONTH
YEAR
MONTH YEAR
18
06 162003
04
29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED ) 1/
A. STATE NEW YORK B. COUNTY 'p~tt'5'i
LOCATION OF CEREMONY
(CHECK ONE AND~CIFY)
o CITY OF ji!r'TOWN OF 0 VILLAGE OF
SPECIFY
SIGNATURE ..
DOH-98 (11/98)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) P l! =1" it Q...
SIGNATURE" ) .~
