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COUNTY Dulchess
CITYITOWN Wa!)pim~er
~~J~~CRT 1368
~o~~J~R 34
STATE OF NEW YORK' I
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert A Filomia
MIDDLE CURRENT SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
11. A. FULL NAME
FIRST
FROM THE BRIDE
Jeannie M, Holmes
MIDDLE CURRENT SURNAME
FIRST
0..
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Holmes
D. sJ~I~~C~Ri;E~U:~~RSE) 107-54-2187
12. RESIDENCE A. NmErork B. ~~~~ness
C. CHECK ONE 0 CITY 0 "'fOWN 0 VILLAGE
~~CIFY Pouahkeepsie
D. STREET ADDRESS 5 Hiah Court ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILlAGE? 0 YES D"" NO
13. A. AGE 4.7 13.B. DATE OF BIRTH 11 / 1", /I ~f.n
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 0 2 96
D. SOCIAL SECURITY NUMBER 97-3 .-3 6
2. RESIDENCE A. t'!~WE)Y ork B. QMlNJ?ess
C. CHECK ONE 0 CITY oITOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
STREET ADDRESS 5 High Court
D.
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILLAGE?
3. A. AGE f\1 3B. DATE OF BIRTH 1 n /
MONTH
ZIP '12603
o YES D" NO
11 / 1~1
DAY YEAR
14. EMPLOYMENT
A. USUAl OCCUPATION Retired Teacher
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Peekskill. New York
(CIlY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Leonard Holmes
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jeaf' C:;:11110etlS110
B. COUNTRY OF BIRTH (j ~ A
18. NUMBER OF THIS MARRIAGE ")
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 n n
B. HOW DID LAST MARRIAGE END? (3) 0 'lSiVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? n:\ / ns / 1 QR~
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 -fes 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
OV05/19S6 PO'19hkf'e-p~ie. N~V" York 0" 0
o 0
o 0
o 0
IS true an~ that I dec are t at no lega Impe iment exists
~
4. EMPLOYMENT
l-
S;
c(
C
u:
I.L.
c(
A. USUAL OCCUPATION Service Technician
B. TYPE OF INDUSTRY OR BUSINESS ,-arner Corporation
5. PLACE OF BIRTH Manhattan - New York
(CIlY. STATEICOuiiifi!iy IF NOT USA)
6. FATHER
A. NAME Louis Filom is
B. COUNTRY OF BIRTH t J S A
7. MOTHER
A. MAIDEN NAME lens l spadllls
B. COUNTRY OF BIRTH t I ~ A
8. NUMBER OF THIS MARRIAGE ')
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
1
(2) O~EATH
1q94
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? n1/ n:\ /
MONTH DjY
D. ARE ANY FORMER SPOUSE(S) AliVE? 0 YES []"l\IO
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
21. SIGNATURE OF GROOM ..
W
en
z
W
o
:J
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This IicensB authorizes the marriage in New York St B of the bridB and groom named abovB by any pBrson authorizBd
RBlations Law ~11 to pBrform marriage ceremoniBs withi NBw York StatB. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checkBd, this IicBnse is to be uSBd onl for thB pur OSB of a sBcond or subsB uent CBrBmon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by NBW York DomBstic
~
{ SEAL }
'-.t-I
NAME (PRINT)
TIME
YEAR
10:51M
PM
06
06 2003
04
08
200
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~tA'J
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF X VILLAGE OF I J
SPECIFY In t'J'J/'t Cti:!I N -:Z't
. 10'1~/
10 CIVIL
NAME (PRINT)
SIGNATURE ..