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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason Monroe Duke
MIDDLE CURRENT SURNAME
.r-
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYfTOWN WaolJinger
~~J~~c~ 1 :,68
~5~\N~R 35
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ni~nlp. F Pirrone
MIDDLE CURRENT SURNAME
1. A. FLU NAME
11. A. FULL NAME
FIRST
FIRST
"-
N B. BI RTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D. S~~~I~~;~Ri~;u~~~~RSE) 2'18-96-8246
2. RESIDENCE A. ~~WE)Y ork B. ~~ess
C. CHECK ONE 0 CITY !Y'TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 5 B Surrey Lane ZIP 1259'0
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D'" NO
3. A. AGE n 3B. DATE OF BIRTH MJ.1 / J.t / yl~80
4. EMPLOYMENT
:<.__ _.__A.-1JSUALDCCUeATION llnitp.dStl'ltp.~.Marinen.
B. TYPE OF INDUSTRY OR BUSINESS ~nvemmfmt
5. PLACE OF BIRTH ~~~~TJm"uJ;;J~YNo~~iY'Rnri
6. FATHER
A. NAME Edward Duke
B. COUNTRY OF BIRTH {I ~ A
7. MOTHER
A. MAIDEN NAME Priscilla 'ikoglumt
B. COUNTRY OF BIRTH I I c;; A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE nllk ~
(OPTIONAL - SEE REVERSE) .....
D. SOCIAL SECURITY NUMBER '1 nL 7h-!=i.-;r47
12. RESIDENCEA. N~~rork B. r~r~!::
C. CHECK ONE 0 CITY DvtOWN 0 VILLAGE
AND . I'll .
SPECIFY vv8r;lp.mgp.r
D. STREET ADDRESS ~ R SI Jrrp...y I Rne ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 2~ 13.B. DATE OF BIRTH MO~~ / i~
14. EMPLOYMENT
_ -A~USUAI.~GGUI'A:r:ION AuditaI'
B. TYPE OF INDUSTRY OR BUSINESS R G I c::; !!'l\I""ninry
15. PLACE OF BIRTH ~.w.~lcPu~RY~t~cf.f' u}:prk
16. FATHER
A. NAME Anthony Pirronp.
B. COUNTRY OF BIRTH i I 5 A
17. MOTHER
A. MAIDEN NAME \!icl:cria Decker
. B. COUNTRY OF BIRTH U '5 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
-1 '~Qn
YES cYNO
~070
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DEATH
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(1
(2) 0 DEATH
(2) 0 DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
YEAR
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. STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose -and say,
as tD my right tD enter iJ'to the marri
21. SIGNATURE OF GRq0M ~
o
o
o
o 0
o 0
o 0
o 0
is true and that I eclare that no legal impe iment exists
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YEAR
2 SIGNATURE OF BRIDE ~ '71' .AI ~ 0 , - ~li'~
USE RENT NAME
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DATE 04/07/200'3
authorized by New York Domestic
urpose of a second or subse uent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
25. B. SOLEMNIZATION.PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-v-I
TIME
MONTH DAY
YEAR MONTH DAY
04
08
200 06 06 2003
29. OFFICIANT
NAME (PRINT)
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF l!i(TOWN OF 0 VILLAGE OF
SPECIFY fA. ") ~~: ~€ r
NAME (PRINT)
SIGNATURE ~
COH.9B (11/98)
SIGNATURE ~