195
-=:t
LC')
-=:t
(")
N
<(
>w
!;;:
.r;" Iii
o
CO
(])
tD
!z m ....
wE: :;:
~~ c(
~ C
5-"" w-
5 _~u..
iJiCll -' u..
z~ ~ c(
0'" z
~~
~c: ~
!!IO i3
me
a:co
~
:$C
a::::J
p
~
~
~
>=
a:
w
u
w
a:
w
:c
~
'"
'"
w
a:
c
c
<
>-
u.
13
w
0.
'"
'I
" )
".J
Z :i
~ g W
ll! ~ ....
>- Z <(
!!l ~ 0
~ @ u::
~ LL i=
~ 0 a::
~ ~ w
w c 0
t; '"
z ~
~TATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
SqgttJ<. Borscl6fjt{RENT SURNAME
COUNTY Dlltchess
CITYfTOWN Wappinger
~5'J~~C: 1368
~5~~J~R 195
1. A FULL NAME
FIRST
0-
N
a. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 125 56 0086
2. RESIDENCE A. V ASTATE) B. \ji~j~ Beach
c. CHECK ONE OIl] CITY 0 TOWN 0 VIUAGE
AND \/"'8 '"
SPECIFY rrglnla eaCl1
o STREET ADDRESS 20R8 Dlfnbarton Dri\Je ZIP 23454
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
~ /~ / ~2
3. A. AGE30
4. EMPLOYMENT
A. USUAL OCCUPATION Military
B. TYPE OF INDUSTRY OR BUSINESS U, S. Na~/y
5. PLACE OF BIRTH~m.UJWPi*~nia
6. FATHER
3B. DATE OF BIRTH
A. NAME Thomas Borschel
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAlDEN NAME Valerie Grooer
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
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
atiLt
/R~ 3/~tJrR
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.A,ud~~ 1\. Paone~NT SURNAME
11. A. FULL NAME
FIRST
a. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE OOrE:cheJ
(OPTIONAL - SEE REVERs!!1
D. SOCIAL SECURITY NUMBER 075 50 8988
12. RESIDENCE AJ.J Y.. B. D. .ft'\h""S&
.... 1STATE) ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND 'AI '
SPECIFY . . appmger
D. STREET ADDRES.'6 G,oloniaJ Dri~~e, 3b ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE43 13.B. DATE OF BIRTH J'JilTH /~~Y 1~
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTHP-fJl'Ka'l'1'i.@~F ~~ York
16. FATHER
A, NAMEF-rank Paonessa
B. COUNTRY OF BIRntJ S A
17. MOTHER
A. MAIDEN NAMECarmella Paganelli
B. COUNTRY OF BIRTflJ S ,1\
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B; HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
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) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
a:
w
"'
::;
:>
Z
c
Z
<
t-
W
W
a:
t-
CJ)
1ST 0 0
2ND 0 0
3RD 0 0
4TH 0 0
e information I provided is true and t at I daclare that n~1 impediment exists
22. SIGNATURE OF BRIDE ~,~~ Q. '\ - fl.ft-Y\.Q f)/)L).,
'\ ~ CURRENT NAME
DATE
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
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 onl for the purpose of a second or subsequent ceremony.
.24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
o
o
o
w
CJ)
Z
W
o
:::::i
~
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE~
DOH-98 (11/98)
'''"''': ~ (
~C._ ~~
TIME
MONTH
DAY
YEAR
MONTH
YEAR
AM
PM 12
27
2002 02
24 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT;PII(1C~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY W~P/~b, r~
ZIP
" .."',,, ro """j. . I L
NAME (PRINT) ~. ~~ ~
SIGNATURE ~
