039
STATE OF NEW YORK ~ STATE FILE NUMBER -,
.., (THIS SPACE FOR STA TE USE ONL Y)
.., Dutchess
COUNTY DEPARTMENT OF HEALTH
CITYfTOWN Wappinaer
DISTRICT 1368 AFFIDAVIT, LICENSE and
NUMBER
REGISTER 39 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME John T. Johnson 11. A. FULL NAME Linda J Barbadillo
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Barhadillo
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 127-4/-8292
12. RESIDENCE A. fi~') Yark B. PJ~~ess
C. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND W .
SPECIFY app1nger
D. STREET ADDRESS 14 Caroline Drive West ZIP 17~9n
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 "I'lo
13. A. AGE 52 13.B. DATE OF BIRTH M~l / oW / t&-iO
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION Mechanic A. USUAL OCCUPATION Cleaner
B. TYPE OF INDUSTRY OR BUSINESS Village Of Sleepy Hollow B. TYPE OF INDUSTRY OR BUSINESS '-ommlJnify RRpti!'<:f ~hlJrr.h
5. PLACE OF BIRTH Tarrvtnwn. New York 15. PLACE OF BIRTH Np.w Yo"" Np.w Y orY
(CITY, ~V IF NOT USA) (CITY, STATElCOUNii!iV IF NOT USA)
6. FATHER 16. FATHER
A. NAME Samuel Johnson A. NAME Angp.1 Aamadillo
B. COUNTRY OF BIRTH USA B. COUNTRY OF BIRTH ~pain
7. MOTHER 17. MOTHER
A. MAIDEN NAME f'lorothy Carney A. MAIDEN NAME Car:men Blanco
B. COUNTRY OF BIRTH l J ~ A B. COUNTRY OF 'BIRTH I IS"
8. NUMBER OF THIS MARRIAGE 3 18. NUMBER OF THIS MARRIAGE ,
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
'} n n 1 1 0
B. HOW DID LAST MARRIAGE END? (3) 0 tfVORCE (3) 0 ANNULMENT (2) q DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C.DATELASTMARRIAGEENDED? na/ n1 / 1QR~ C. DATE LAST MARRIAGE ENDED?, 07/ 09/ :m01
MONTH ,~DAV VEAR MONTH DAV v~!I"
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 'l'ES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 'fils 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1nf1nt1918 White Plains New Yolt 0 '" 0 1ST 12108/1971 New York, N~w York 0 "" 0
08101f1Q83 White PIRin~: Np.w York' 0'; 0 2ND n7/nQ/7nn1 POt'gI1lfpppsie, New York 0.... 0
o 0 ~D 0 0
o 0 4TH 0 0
and belief that the information I provl ed is true and that declare t at no legal impedimeQt exists
- 22. IGNATUREOFBRIDE~ ~ ~ ~
U~r:URRENT NAME
23. ~~~fr~=~Do~Ni'o~Ocf~ T CLERK ~ V DATE n.i/11 /;mn~
This license authorizes the marriage in the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne ork State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 075-"'6 212"l
D. SOCIAL SECURITY NUMBER _ _..1_- ___~
2. RESIDENCE A. New York
(STATE)
c. CHECK ONE 0 CITY 0 .fOWN
AND W .
SPECIFY applnger
D. STREET ADDRESS 14 Caroline Drive West ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ooflo
3. A. AGE ~~ 3B. DATE OF BIRTH n'\ / 7Q / 194-
MONTH DAV . VEAR
8.~hess
( )
o VILLAGE
1ST
2ND
3RD
4TH
I, being duly sworn, depose an
as to my right to enter into the
21. SIGNATlURE OF GROOM ~
~
{ SEAL }
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
AM
02:26M
10 2003
12
20 3 06
04
IP
ATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
:~::~~:II:::ED. . ~
NAME (PRINT) V l
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 7JvTCflr=.JJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY IVAff/NG-E t<..
1~CIVIL
fl.
'ItIP~ G
STREET CITYfTOWN
30. WITNESS TO CEREMONY .
"M'("~ E:::!~ ~
SIGNATURE~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE~
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