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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~af\l M n~wi~
MIDDL"E CURRENT SURNAME
23. SUBSCRIBED AND SWORN TO BEFORE ME 0 0
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 10/ 2/2 02
This license authorizes the marriage in New York the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit 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
SPECIFY
Lutheran 55 Wilbur Boulevard, Poughkeepsie, NY 12 03
CITYITOWN STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) Jam
COuN-rvOutchess
CITYfTOWNWappinger
~~J~~CRT1368
~G~'~J~R160
1. A. FULL NAME
FIRST
"-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE~
D. SOCIAL SECURITY NUMBER 12'-fiR-7M9
2. RESIDENCE ANew York B. nlJtr.he~5l
(STATE) (COUNTY)
C. CHECK ONE 0 CITY>U TOWN 0 VILLAGE
AND W ..
SPECIFY applnger
o STREET ADDRESS 166B Route 9 Unit 3d ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"'D NO
3. A AGE32 38. DATE OF BIRTH~:irH /O~AY /l~kD
4. EMPLOYMENT
A. USUAL OCCUPATION C:nn~tnldinn Wnrkp.f
B. TYPE OF INDUSTRY OR BUSINESsLocal -11
5. PLACE OF BIRTfft:ockville Centre New Yor)(
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Gary navi5l
B. COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME .Ioan Smith
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
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
(2) 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
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21.
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{ SEAL }
'-v-I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10-12-02
OXXRELlGIOUS
9 0 OTHER, SPECIFY
29. OFFICIANT Daniel B. Ward
NAME (PRINT)
SIGNATURE~~d~~
MAILING ADDRESS
St. John's
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) Christine
TITLE
DATE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
1Jf,J; Ip-t5-t1K
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Patrir.ifl A VRla
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Oavi~
(OPTIONAL. SEE REVERSEh
D. SOCIAL SECURITY NUMBER ~1-flfi.4R~~
12. RESIDENCE ANew V nrk B. nlltr.he~~
(STAtE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \AI ..
SPECIFYlI'vapplnger
D. STREET ADDREss166B Route 9 Unit 3d ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
13. A. AGE3G 13.8. DATE OF BIRTH --1tTH /11;,AY t9~R
14. EMPLOYMENT
A. USUAL OCCUPATIONs'pninr Fimmf'~ Ansly~t
B. TYPE OF INDUSTRY OR BUSINEssf:Jepsi
15. PLACE OF BIRTHYonkers. Np.w York
(CITY, STAfE7COUNTRY IF NOT USA)
16. FATHER
A. NAMERonflld Vals
B. COUNTRY OF BIRTtlJ S A
17. MOTHER
A. MAIDEN NAMEAngela flJrit~tti
B. COUNTRY OF BIRTtU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
(2) 0 DEATH
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
1ST 0 0
2ND 0 0
3RD 0 0
4TH 0 0
at the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~
f>trbu ~iL if t.d~
USE CURRENT NAME
TIME
MONTH
YEAR
MONTH
YEAR
AM
PM
10
03
2002 12
01 2002
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY nllt"('hp~~
Pastor
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
XJ CITY OF 0 TOWN OF 0 VILLAGE OF
Poughkeepsie
1O-1? O?
SIGNATURE ~