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COUNTY Dutchess
CITYITOWN WODpinger
2~~~ 136B
~5~~R 14
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Adam A. Monti
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONLY)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Laurene K. Butrica
MIDDLE CURRENT SURNAME
.-J
1. A. FWNAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Monti
D. Sci~~~I~~;;:-Ri~E~u~~~RSE) 067-54-7049
12. RESIDENCEA...NtK,'yOrk B. ~~ss
C. CHECK ONE rl CITY 0 TOWN 0 VILLAGE
~~CIFY Beacon
D. STREET ADDRESS 35. Tompkins Terrace ZIP 12508
E. IS RESIDENCE WITHIN UMrrs OF CITY OR INCORPORATED VILLAGE? l!!' YES 0 NO
13. A. AGE 47 13.B. DATE OF BIRTH ~H /1.Ry /f'~
14. EMPLOYMENT
A. USUAL OCCUPATION None
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH q~,'RTE/tt~,X.uSA)
16. FATHER
A. NAME I RWfenr.p. Andrp.w Rurtir.a
B. COUNTRY OF BIRTH II c;:; P.
17. MOTHER
A. MAIDEN NAME Do~onlyanR Mary HaRuA~r1e
B. COUNTRY OF.BIRTH II SA
18. NUMBER OF THIS MARRIAG~ 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
B. B1RlH NAME. IF mFFERENT
c. SlJANAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 0 94
D. SOCIAL SECURITY NUMBER 79-18- 07
2. RESIDENCE A. NWn}'ork B. ~ess
c. CHECK ONE 0 CITY r!1 TOWN 0 VILLAGE
~CIFY WapDinger
D. STREETADDRESS 176 Town View Drive ZIP 12590
E. IS RESIDENCE wmllN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES I!f NO
3. A. AGE 78 3B. DATE OF BIRTH~ / U.. / 'JJ1l4
4. EMPLOYMENT
A. USUAL OCCUPATION Retired
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH ~~~~F.wr~rk
6. FATHER
A. NANE Adam Monti
B. COUNTRY OF BIRTH I J c;:; A
7. MOTHER
A. MAIDEN NANE Mary De FraRcestO
B. COUNTRY OF BIRTH II 5 A
8. NUMBER OF THIS MARRIAGE ,
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
n n 1
B. HOW mo LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) rfDEATH
C. DATE LAST MARRIAGE ENDED? n7/ 71 / 1~~~
MONTH _RAY VEAi'i
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES C!f NO
10. .IF PREVIOUSLY DIVORCED OR ANNUUED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY, STATEICOUNTRY:IF NOT USA) SELF SPOUSE
DEATH
n
(2) 0 DEATH
,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) SEUF SPOUSE
YEAR
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{ SEAL }
'-.-'
MONTH
YEAR MONTH
YEAR
AM
PM
02
21
200 04 21 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~reJl4S!:.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J& TOWN OF 0 VILLAGE OF
SPECIFY Fr.:slll</JJ-
.
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PAINT)
NAME (PRINT)
SIGNATURE ~
DO~ (1 1198)
Tt? eas ;1lt'tlS'rlf
............,."....,............. ..u..,....~._"...~ _.~... '" -'~"",. ....... '. .
SIGNATURE
rr-