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COUNTYnlltch~s<:;
CITYfTOWN\A!;:1 ppinOF'r
~~J:~c~13f\R
REGISTEfJ;)
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Randfrlll D Simoniette
M DDLE CURRENT SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1 A. FULL NAME
I inrl;::l fin niring1='r
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTG regs
C. S~~~~~N1r~~~t~~C~~~biringer - Simoniptte
D. SOCIAL SECURITY NUMBER 75-50-9818
12. RESIDENCE A(\1~~TXWk ~'" B.nlltg~~~c:;
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~gcIFY wi A-PP I~ 4 n.-
D. STREET ADDRESO 1 nAi~y I ;::me zIP1 ):'190
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
13. A. AGF'Jr8 13.8. DATE OF BIRTH hUTH /~AY 1''S~:h
14. EMPLOYMENT
A. USUAL OCCUPATloNSllrgical Dental Assistant
B. TYPE OF INDUSTRY OR BUSINEss[)r I=renk \liolintti
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
11. A. FULL NAME
FIRST
a.
N
8 BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE.L
D. SOCIAL SECURITY NUMBER ']61-96-8685
2. RESIDENCE ANe~A'1Rrk B D~t'if~ss
C. CHECK ONE 0 CITY..cJ TOWN 0 VILLAGE
AND \^/ .
SPECIFY apprnger
D. STREET ADDRESS? 1 n:::lisy I (In1=' ZIP 1 ?!=lqO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE9o't] NO
3. A. AGE53 38. DATE OF BIRTH JfJrH / ~Y / f~~9
4. EMPLOYMENT
A. USUAL OCCUPATION Boat Builder
8. TYPE OF INDUSTRY OR BUSINEssStorm King Marine Center
5. PLACE OF BIRTf-8~~9.t~coM#mi~USA)
6. FATHER
16. FATHER
A. NAME Randall Simoniette
8. COUNTRY OF BIRTH U S P-
7. MOTHER
A. MAIDEN NAME Marietta Hardy
B. COUNTRY OF BIRTH U S ft.
8. NUMBER OF THIS MARRIAGE ::2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME; John Grega
B. COUNTRY OF BIRTtli I S A
17. MOTHER
A. MAIDEN NAME~IiZ:3b€lth Spi@gs!
B. COUNTRY OF BIRTtU S A-
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~ DEATH
C. DATE LAST MARRIAGE ENDED? ~ / '\ A / 1 aa7
MONirr- ilA'Y vtOAA
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ~ 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
1
a
a
a
B. HOW DID LAST MARRIAGE END? (3"rJ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? n2 / ")4 / "9Q.(}
MONTfF Ol\Y l ~I'f
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
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
a:
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1ST 02/21/1991 Hudson, New York
2ND
3RD
4TH
I, being duly sworn, depose and sa ,
as to my right to enter into the marriage
21. SIGNATURE OF GROOM.
o
o
o
~ 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
d e and belief that the information I provided is true and
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
by New York Domestic
~
{ SEAL }
'-v-l
NAME (PRINT)
MONTH
YEAR
YEAR
MONTH
DAY
TIME
28 2003 03 28 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. CO~~
1
ZIP
1~L
z Z LOCATION OF CEREMONY
a: 0 W C.
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l- I- (CHECK ONE AND SPECIFY)
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0 NAME (PRINT)
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SIGNATURE.