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COUNTJ:1utchess
CITY/TGNNVljapl)imler
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Andrew E. Dinobile
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
/CJ;1-dR
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dorothv M. Braaer
MIDDLE CURRENT SURNAME
.J
11. A. FULL NAME
FIRST
1 A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Dinobile
D. S6~~~I~~t~RiT~E~U~~~~RSEb73-62-9300
12 RESIDENCE AMA BPlvmouth
(STAlE) lCOUNTY)
C. CHECK ONE "lJ CITY 0 TOWN 0 VILLAGE
~~~cIFyBrocldot1
D STREET ADDRES~O Oak Street Ext Apt. #402 z1P023.01
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "6 YES 0 NO
/14 1977
DAY YEAR
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE-. ~ '1
D. SOCIAL SECURITY NUMBER ufl7-74-"~2.. 2
2 RESIDENCE AM~STATE) B PI~mN9y~th
C CHECK ONE "'lJ CITY 0 TOWN 0 VILLAGE
~~~CIFY Broddon
D STREET ADDREss50 Oak Street Ext. Apt. #402 ZIP 02301
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "I'J YES 0 NO
3 A AGF26 3B. DATE OF BIRTH nR /1!; /1!Hn
MONTH DAY YEAR
13. A. AGE':;M
13.8. DATE OF BIRTH
11
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATIONEnvironmental Chemist
B. TYPE OF INDUSTRY OR BUSINESS \,flJoods Ho.!e Gro.up
15. PLACE OF BIRTJ!ronxville. New York
(CITY, STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Fund Accountant
B. TYPE OF INDUSTRY OR BUSINESslnves\ors Bank &. Trust Co._
5. PLACE OF BIRTrBronxville. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEDavid Bracer
8. COUNTRY OF BIRTM S A
17. MOTHER
A. MAIDEN NAME Dorothv Bolan
B. COUNTRY OF BIRTM S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
6. FATHER
A. NAME Andrew Dinobile
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME K:=m:m Swatnwy
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? 13} 0 DIVORCE (3) 0 ANNULMENT 12) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 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
B. HOW DID LAST MARRIAGE END? 13} 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
12) 0 DEATH
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say. t
as to my right to enter into the marria
21. SIGNATURE OF GROOM ~
o 1ST
o 2ND
o 3RD
o 4TH
lief that the information I provided is tr
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by New York Domestic
22. SIGNATURE OF BRIDE ~
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23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi 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
{ } NAME (PRINT) Glo "8
TIME MONTH
SEAL SIGNATURE"/ ATE'10/0712002
'-v-' MZ N r~bush Rd in er Falls NY 12590 09:33 AM 10
CI YITOWN STATE ZIP PM
27. TYPE OF CEREMONY
YEAR 0 0 RELIGIOUS
9 0 OTHER, SPECIFY
YEAR
26. SOLEMNIZA I OCCURRED
TIME MO. DAY
JJ; .,
7,30 PM 16-19- d V-
~om,,~' ~. ~~
NAME (PRINT) t1V we;
SIGNATURE ~ - C~~ A dj,,~
JrLlNG ADDRESS A
rJe",r 1"'7( (U f'1l1tf)// t
STREET CITY/TOWN
30. WITNESS TO CEREMONY
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Q;rCh'.fS(
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMEO ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1 'fi CIVIL
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~
J Jus 77c..f.
ItJ-/4-tra/
TITLE
o CITY OF III TOWN OF 0 VILLAGE OF
It t113 /1/1 J
DATE
SPECIFY
N~
' ST TE
I)/SOI
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) r l!A-IlF<:>:1 ~~"2/ n
SIGNATURE~ ....--::::. --- .1 ~
NAME (PRINT)
SIGNATURE ~
DOH-98 111/9B)