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COUNT.,qutchess
.GITYiTOW~Wappinger
~~~~~CR" 368
~G~I~J~R166
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Yves Fore
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
4Jrl
/p..1-tJR
L 0 SUPPLEMENTAL FILE
-.J
1. A. FULL NAME
FROM THE BRIDE
Lucy S. Davis
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTSaldutti
C. SURNAME AFTER MARRIAGE Fore
(OPTIONAL - SEE REVERSEIi 46-40-2302
D. SOCIAL SECURITY NUMBER '1
12. RESIDENCE~ew York BDutchess
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
AND W .
SPECIFY'" ~ applnger
D. STREET ADDRES~6 Scnbo f"(oad
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERS~56-82 5333
O. SOCIAL SECURITY NUMBER -
2. RESIDENCE ANew York B. Manhattan
(S~TE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY New York
D. STREET ADDRES~59 West 45th Street
ZIP 14!~~U
~
DYES 0 NO
1-953
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGA8 13.B. DATE OF BIRTH 12 ~6
YEAR
3. A. AG~5
12
MONTH
YES 0 NO
/\966
YEAR
MONTH
DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATIONCustomer Service Representative
B. TYPE OF INDUSTRY OR BUSINESsResearch Inst. Of Amer.
15. PLACE OF BIRT~eth Amoy, New Jersery
(CITY, STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATIONA.ccount Manager
B. TYPE OF INDUSTRY OR BUSINESsAmerican Tours Int'l
5. PLACE OF BIRTtA1es, France
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAM~hartes Saldutti
B. COUNTRY OF BIRTtV S A
17. MOTHER
A. MAIDEN NAMEAnne BarriceUi
B. COUNTRY OF BIRTM S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DlOTH
t::
6. FATHER
A. NAME Gabriel Fore
B. COUNTRY OF BIRTHFrance
7. MOTHER
A. MAIDEN NAME Marie Jeanne Navarette
B. COUNTRY OF BIRTH France
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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B. HOW DID LAST MARRIAGE END? (310 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT fif DEATH
c. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 08 /01 /19
MONTH DAY YEAR MONV DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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 dMONTH, DAY, YEARl. (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 8/01/1997 poughkeepsie, New York ~ 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~H 0 0 ~H 0 0
I, being duly sworn, depose and say, that to the best of .-my knowledge and belief that the information I provided is true and t t I deCla~e tole al impediment exists
as to my right to enter into the marria state.
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
E CURRENT NAME
23. ~~~..fT~~~Do~N~o~Ot~ ci~B cE~~~~E DATE 10/04/2002
This license authorizes the marriage in New York St authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew 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 CL]=RK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glons .
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
MAJ~J\Ql:! 8:50 AM 10
"-y-I "u Mlm e ush PM 05 2002 12 03 2002
STREET liP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
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(,)
:J
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY j)t/r?:/!6S
1 5t CIVIL
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
C. LOCATlbN OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF fll TOWN OF 0 VILLAGE OF
SPECIFY lih/-p/NG-.!iE/2
29. OFFICIANT
NAME (PRINT)
TITL;fNt/llMJ ~~mc.-;/f 29/
DATE de/. 6, fl;t12-
'IN ~R.S mm illY: /~ 'tl
STATE
SIGNATURE ~
DOH-98 (11/98)
ZIP
31. WITNESS TO CEREMONY
".'<,,,,,, t=- SI'1J..i>t.fT I
SIGNATURE ~ ~JA::t/!j;: