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168 ~ t- .... ~al :> ~'r-! < oUl C ..J w- 5al~lL :r: al -' lL en~~< ~..c::~ ~ ::l g ~ 0 ~ aP-iU W '" " ~ al ~ ::- ""r-! ~ l-l :A 8.-/ 5:;1 ~::q ffi>, Ul-l l:!l-l Wal", ~..c:: :Jj ~u ~ W Z "',...; 0 go ~ <(I.t'\ f- ~r-f * ~ ~ CL en z z '" 0 W ::> >= t- .... W <( '" N < t- Z en ::; 0 ::> W ::; 6 u: t- en z i= <( u- U 0 a: u: u- en W 0 >- <( 0 W 0 ~ '" 0 Z ~ 1. A. FULL NAME STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM William E. Blasetti CURRENT SURNAME I Ph ~~r STATE FILE NUMBER (THIS SPACE FOR STATE USE ONL Y) COUNTY Dutchess CITYfTOWN Wappin~er ~~J~~C;; 13 6 8 ~E~~J~R 168 #rvdd at k/~~ IPli~ll~ L D SUPPLEMENTAL FILE FROM THE BRIDE Christine M. Kazimir CURRENT SURNAM E 11. A. FULL NAME FIRST MIDDLE FIRST MIDDLE CL N B BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER 12. RESIDENCE A New York B. C. CHECK ONE (STAO) CITY Xi TOWN 0 VILLAGE ~~~CIFY Pou~hkeepsie D. STREET ADDRESS 1501 Cherry Hill Drive ZIP 12603 C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER 2. RESIDENCE A New York (STATE) C. CHECK ONE 0 CITY I]l! TOWN 0 VILLAGE AND hk SPECIFY Pou~ eepsie D. STREET ADDRESS 1501 Cherry Hill DrivezlP E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 /10 DAY 094-62-1919 Dutchess (COUNTY) Kazimir 086-70-7775 Dutchess (COUNTY) B. 12603 YES IX NO /1964 YEAR E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Xi NO 13.B. DATE OF BIRTH 06 / 12 /1970 DAY YEAR 3. A AGE 38 04 13. A. AGE 32 38. DATE OF BIRTH MONTH MONTH M o~ "'-< Nlii ,...; 4. EMPLOYMENT 14. EMPLOYMENT A USUAL OCCUPATION Machine Operator 8. TYPE OF INDUSTRY OR BUSINESS Montfort Bros. 5. PLACE OF BIRTH New York, New York (CITY, STATE/COUNTRY IF NOT USA) A. USUAL OCCUPATION Receiving Administrator 8. TYPE OF INDUSTRY OR BUSINESS Home Depot 15. PLACE OF BIRTH Yonkers, New York (CITY. STATE/COUNTRY IF NOT USA) 6. FATHER A NAME B. COUNTRY OF BIRTH 7. MOTHER A. MAIDEN NAME Evelyn Martin 8. COUNTRY OF BIRTH u. S. A. 8. NUMBER OF THIS MARRIAGE One 16, FATHER A. NAME 8. COUNTRY OF BIRTH 17, MOTHER A MAIDEN NAME 8. COUNTRY OF BIRTH 18, NUMBER OF THIS MARRIAGE Frank Kazimir u. S. A. Thomas V. Blasetti U. S,A. Marie DeYorio U. S. A. One 9, PREVIOUS MARRIAGES A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT 19, PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT DEATH DEATH 8. 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 (3) 0 ANNULMENT / / (2) 0 DEATH 1ST 2ND 3RD o o o o o o w en z w o ~ E 23. SUBSCRIBED AND SWORN TO BEFORE ME T CI k 0 10 2002 SIGNATURE OF TOWN OR CITY CLERK ~ own er DATE ct. , This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic Relations Law 911 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 ~ { SEAL } '-,-I Town Clerk DATE 10/10/02 ers Falls, NY 12590 CITYrrOWN STATE 27. TYPE OF CEREMONY e YEAR NAME (PRIN --- TIME MONTH YEAR MONTH SIGNATURE .. MAILING ADDRESS P.O. Box 32 STREET I CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF THE PER- SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND PLACE INDICATED. 29. OFFICIANT~ NAME (PRINT) q::1t ZIP AM 1: 10 PM 10 11 02 12 09 2002 28. PLACE WHERE MARRIAGE OCCURRED A, STATE NEW YORK B. COU~~~ C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) /' o CITY OF 0 TOWN OF .;!1ILLAGE Ov }I/ ECIFY UJA1'PIi\b~rt8 'tRU8 RELIGIOUS OTHER, SPECIFY 1~ . NAME (PRINT) SIGNATURE" , DOH-98 (11/98) NAME (PRINT) SIGNATURE ~ ยท