176
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH B. HOW DID LAST MARRIAGE END? (3) r1 DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 04 / 06 /2000
MONTH DAY YEAR MONT.flr DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING 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
D D 1ST 01/05/1995 Camden, Georgia D ~
D D 2ND 04/0612000 Pensacola, Florida ~
D D 3RD D
D 4TH
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael p" Grimaldi
MIDDLE CURRENT SURNAME
CouNrvQutchess
CITYITOWN Wappinger
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~5~~J~R176
1. A, FULL NAME
FIRST
11.
N
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERS""78 5'" .of.of.of
D. SOCIAL SECURITY NUMBER U - ~ 1
2. RESIDENCEA.New York B. Dutchess
(STATE) (c5u~)
C. CHECK ONE D CITY vtJ TOWN D VILLAGE
~~~CIFY FishkiJI
STREET ADDRESS 1518 Max Way ZIP 12524
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES'tJ NO
07 /1~ /1QR~
MONTH DAY YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
D.
E.
3. A. AGf~~
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Assistant Manager
B. TYPE OF INDUSTRY OR BUSINESSS T S Tire
5. PLACE OF BIRT~ount Vernon. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert Grimaldi
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Carol Le Viness
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
o 0
DEATH
o
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer L Dries
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Grimaldi
D. sJ~I7t:I~~~LRi~E~U~~~~RSE)241_13-8234
12. RESIDENCE ANeIrX?rk B. Di~u~~fS
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~c,FYEishkiJI
D. STREETADDREss1518 May Way z,P12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES 'tj NO
13. A. AGE35 13.B. DATE OF BIRTH nR &~ :t:9~7
;;ro'lilTH LlA Y VEAR
14. EMPLOYMENT
A. USUAL OCCUPATIONResidential Property Manager
B. TYPE OF INDUSTRY OR BUSINESSJ P r
15. PLACE OF BIRTHLincolntonol North Carolina
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEDavid Cook
B. COUNTRY OF BIRT.tJ S A
17. MOTHER
A. MAIDEN NAME Ka7uko Oi~hi
B. COUNTRY OF BIRndepen
lB. NUMBER OF THIS MARRIAGE 3
DEATH
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23. SUBSCRIBED AND SWORN TO eEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York tate of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi n New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the U ose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PR.'NT) Glo " TIME MONTH DAY YEAR MONTH
SEAL SIGNATURE ~ -
'-v-/ M~~N~~'J6ush Rd 1."13 ~~ 11 13 2002 01 11 2003
STREET C
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE IME MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED,
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YEAR
STAT
27. TYPE OF CEREMONY
o D RELIGIOUS
9 D OTHER, SPECIFY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
1 ~CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY /)vicHESJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF p( TOWN OF D VILLAGE OF
SPECIFY FISH f<' (L L
.
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) e.V /I .L E J/ / /YES S
SIGNATURE~ '-(_ -tv ~