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COUNTYDutchess
c.;.."YfTOw~Wappinger
2~J~~C:1368
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Henry M. stanley. JR.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
1. A. FULL NAME
11. A. FULL NAME
4Mt
I/~ ~-ti ~
FIRST
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cara M. Cava
MIDDLE CURRENT SURNAME
--.J
FIRST
B. BIRTH NAME, IF DIFFERENT
f,. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEk95-64 7779
D. SOCIAL SECURITY NUMBER U -
2. RESIDENCE A. New York B. Dutchess
(ST A TE) (COUNTY)
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
~~~CIFY Pouahkeepsie
D. STREET ADDRESS 70 Hillcrest Drive ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"fJ NO
3. A. AGr::22 3B. DATE OF BIRTH OR /07 /1 gElO
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Stanley
(OPTIONAL. SEE REVERSE)133-6C1771
D. SOCIAL SECURITY NUMBER U-
12. RESIDENCE ANew York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFYPouahkeepsie
STREET ADDRESS 70 Sheafe Manor ZIP 12590
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ti ND
AJ~ ttJR7
DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION UnerriDloyed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTHMount Vernon. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Ronald Cava
B. COUNTRY OF BIRnU S A
17. MOTHER
A. MAIDEN NAME .hinet f:inffoletti
B. COUNTRY OF BIRT..LJ S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
13.B. DATE OF BIRTH
09
MONTH
D.
E.
13. A. AGE70
4. EMPLOYMENT
A. USUAL OCCUPATION Plumbina & Heating
B. TYPE OF INDUSTRY OR BUSINESS G H Plumbina
5. PLACE OF BIRTHPouahkeepsie. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Henry Stanley
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Susan Young
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
DEATH
o
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o 1ST
o 2ND
o 3RD
o 4TH
lief that the information
rJX
. 22. SIGNATURE OF BRIDE
o
o
o
10/29/2002
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0 TIME MONTH YEAR YEAR
::i AM
PM 10 30 200
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2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AN)! SPECIFY)
o CITY OF ~TOWN OF D VILLAGE OF
SPECIFY