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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Keith A Angot
MIDDLE. CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYITOWN Wappinger
~~J~~<ii 1368
~5~':~R 20
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Eve Marie Godin
MIDDLE CURRENT SURNAME
1. A FUll NAME
11. A. FUll NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIALSECURllYNUMBER 081-66-417:\
2. RESIDENCE A ~Wr:)York B. ~ess
C. CHECK ONE 0 CIlY 0 TOWN [!"'VILLAGE
~~~CIFY Wappingers Falls
D. S1REET ADDRESS 199 Old Route 9 Apt A 12 ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CIlY OR INCORPORATED VIllAGE? o'YES 0 NO
3. A. AGE 36 3B. DATE OF BIRTH nR / l4 / 1 R6G
MON'I'H DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Angot
(OPTIONAL. SEE REVERSE) 6 58-7 71
D. SOCIAL SECURllY NUMBER 0 7- 6
12. RESIDENCE A N~~rork B. q~M)ess
c. CHECK ONE 0 CITY 0 TOWN []"'(,ILLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 1~9 Old Route 9 Aot_ A 12 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILLAGE? D'" YES 0 NO
13. A. AGE ~~ 13.B. DATE OF BIRTH 1 n /" A Rli7
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Nursing Assistant
B. TYPE OF INDUSTRY OR BUSINESS Wingfttp. Of nLofr.hess
15. PLACE OF BIRTH Rear-on New Yor((
(CITY, STATEiCliUNTRY IF NOT USA)
16. FATHER
A. NAME I awrence Godin
B. COUNTRY OF BIRTH I' ~ A
17. MOTHER
A. MAIDEN NAME Y'!OrUUI Tr-il'tis
B. COUNTRY OF BIRTH f r '5 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
4. EMPLOYMENT
A. USUAL OCCUPATION Contractor
B. TYPE OF INDUSTRY OR BUSINESS ~p.lf _ Fmplnyp.d
5. PLACE OF BIRTH Rrnnv Nl!'!w Vnrlt
(lfrIY, SfAml!&INfiiYiFNOT USA)
6. FATHER
A. NAME r.:lalJdp. An9~t
B. COUNTRY OF BIRTH I I -> A
7. MOTHER
A. MAlDEN NAME MaRe Rezzosgli
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
n
(2) 0 DEATH
DEATH
n
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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, STAlE/COUNTRY, IF NOT USA) SELF SPOUSE
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) (CIlY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
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21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CIlY CLERK ~
This license authorizes the marriage in New York Sta authorized
Relations Law ~11 to perform marriage ceremonies within W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl
24. TOWN OR CIlY CLERK
~
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
03
05
200
05
03 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~~~,.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF II!f"vILLAGE ~ JL
PECIFY IIJ~/~ ~
SIGNATURE ~
DOH-98 (11/98)