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COUNrOlltchE'5S
CITYfTowr-!^'appinger
~~J~kc~ 368
~5~I:J~~ 89
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Chris S np P::llm::l
MIDDLE CURRENT SURNAME
I
flRl
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
M. 3 j-- d~
L 0 SUPPLEMENTAL FILE
1. A. FUll NAME
FROM THE BRIDE
Carol A. Hotte
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DlFFEREN1Silakowski
c. SURNAME AFTER MARRIAGE De Palma
D. scig~~I~~tJRiT~E~U~~~~RSE, 33-36~6375
12. RESIDENCE ..conp!cticut B.Litchfield
(S ) (COUNTY)
C. CHECK ONE CITY 0 TOWN 0 VILLAGE
AND _ C' " b
SPECIPtUa IS urv
D. STREET ADDRES~ T~e Lockup ZIpQ6068
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ..to YES 0 NO
13. A. AG.f\R 13.B. DATE OF BIRTH 07 /4 2 ;1'946
MONTH DAY YEAR
11. A. FUU NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE..\,
D. SOCIAL SECURITY NUMBER u94-40-0647
2. RESIDENCE AN '(STATE) B. D'lgo~~~!=:
C. CHECK ONE 0 CITY..cJ TOWN 0 VILLAGE
AND ^' .
SPECIFY \ applnger
D. STREET ADDRESS.' ()nnnrl::lg;::l nriv@. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEs-1J NO
M~ /~Y /t2~6
3. A. AGE53
4. EMPLOYMENT
A. USUAL OCCUPATION Comp'lter Progr:::lmmpr
B. TYPE OF INDUSTRY OR BUSINEssH r. I .Innp!=: T@.ch
5. PLACE OF BIRTt-P-......kc;j,(jll !\''''''^' V nrk
lClTY. in'A'PETeoU;:mrv IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATIONMedical Assistant
B. TYPE OF INDUSTRY OR BUSINEssN W UrolOQV P. C.
15. PLACE OF BIRTt-8rooklvn. New York
(CITY. STArE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEEdward Silakowski
B. COUNTRY OF BIRTtU S A
.17. MOTHER
A. MAIDEN NAMEM;::lYinp SnlJ~Y
B. COUNTRY OF BIRT..LJ S A
1 B. NUMBER OF THIS MARRIAGE 2
A. NAME JOS€lph D~ P61lma
B. COUNTRY OF BIRTH I I S Ii
7. MOTHER
A. MAIDEN NAME Ida Lent
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
0:
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III
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DEATH DIVORCE CIVIL ANNULMENT
1 001 0
B. HOW DID LAST MARRIAGE END? (3)>tJ DIVOR~E. (3) O.ANfULMENT q) D,DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 1,.. / t. / 1. B~ c. DATE LAST MARRIAGE ENDED? 04 / 10 /1991
. MONTH DAY YEAR MONTtli DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? i:I YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOULOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST __!'lJJlfR(J POblghk~epiie, New York 1!1 D 1ST 04/10/1991 Dutchess County. New 0 r5'
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 D
I. being duly sworn, depose and say, that to the best of my' knD~dge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marria st~te. I lJ rv.. /i
21. SIGNATURE OF GROOM ~. ...f. ~ 22. SIGNATURE OF BRIDE ~ ("Ail a ~
USE CURRENT # USE CURRENT NAME
~
DEATH
o
DATE
12/13/2002
W
en
z
W
o
:J
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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
. by New York Domestic
~
{ SEAL}
'-,i-I
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
MONTH
DAY
YEAR
YEAR
TIME
MONTH
ZIP
08:44 ~~ 12
14
2002 02
11 2003
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1)( CIVIL
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY i!LS7'E.}
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF D VILLAGE OF
SPECIFY IH/If<f>Lf:./OWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
~1f5= /1.- 2./ (J2.
29.0f'FICIANT ~LJ"I t::. IJ~~' -;:n' -r.()/)JIJ -t1/<"''''''IC/~
NAME (PRINT) V" i (IY 1;;... ~ ~ '''~;~LE I c. "'I I,J l4-V' &;.0
SIGNATURE'~ L . DATE /'2..- Z,/- 0-;"
3~G;JD~ 2,8/1 /-Ic.lRLetf N.t? J2-Lf4f3
STREET CITYfTOWN STATE ZIP
3D. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
(V\ p.~ I.
NAME (PRINT)
SIGNATURE ~