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COUNT'Rutchess
CITYiTOW~appinger
~~J~~CR~ 368
~[j~~J~158
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
GreQori J. White
MIDDLE CURRENT SURNAME
I
.~
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
}I ) 5 ~ CJ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tara C. Marsala
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSi\fl"l 66 9'167
D. SOCIAL SECURITY NUMBER U l}oI!'.- -.J
2. RESIDENCE ANew York 8. Dutchess
(STATE) u/; (COUNTY)
C. CHECK ONE 0 CITY- 0 TOWN 0 VILLAGE
AND P l k .
SPECIFY OUgrl eepSle
D. STREET ADDRESl6 Ridge View Road ZIP 12603
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 yES..... 0 NO
/04 /1981
DAY
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE White
D Sci~I~~I~~t~R'IT;E~U~~~~RSE()61-68-8831
12. RESIDENCE fJew York BDutchess
(STATE) ..L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~clF}flIappinger
D STREET ADDRES~3A ~car!;)orougn Lane
lZ....tln
ZIP ,......,-
.;
o YES 0 NO
t883
YEAR
3B. DATE OF BIRTH
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE19 13.8. DATE OF BIRTH 05 ;f9
MONTH DAY
3. A. AGF20
12
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATIONTelephone Interviewer
B. TYPE OF INDUSTRY OR BUSINESSQ - searcn me.
15. PLACE OF BIRT~eacon, New York
(CITY, STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATIONU S Coast Guard
B. TYPE OF INDUSTRY OR BUSINESSGovemment
5 PLACE OF BIRT~oughkeepsie, New York
(CITY. STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAMPhilip Marsala
B. COUNTRY OF BIRT;\rJ ti A
17. MOTHER
A. MAIDEN NAMEUnda Martin
B. COUNTRY OF BIRT~ S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D8'ORCE CIVil A'6'ULMENT
DWH
6. FATHER
A. NAME Donald White
8. COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME Unda Sammarco
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
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
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
1 ST 0 0 1 ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, bemg duly SWDrn, depose and say, that to the best of my knowledge and belief that the Information I provided IS true an~ declare that no legal Impediment exists
as to my nght to enter mto the mama state. ,;? <.::::7')~ /7~ .//
21 SIGNATURE OF GROOM ~ ~ 22. SIGNATURE OF BRIDE ~~ L '; /C~~~
AME USE CURI'lENT NAME
DATE 09/30/2002
W
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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 Stat of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within W 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) Glona J.
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 09/30/2002
'-.,,-I ~~[~~dfJ6uSh Rd, Wa jfJI~e w~alls, N~TA~E2590 ZIP '11:17 ~~ 10 01 2002 11 29 2002
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY 2B. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER. ~ .
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS 1 CIVIL EW ORK 0:+4 ~ c-
OATE AND AT THE TIME AND A. STATE N Y B. COUNTY Ol.. e. ~
PLACE INDICATED.
YEAR
k.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~WN OF 0 ~ILLAGE OF
SPECIFY tJA.ff'''''je ~
NAME (PRINT)
SIGNATURE ~
DOH.9B (11/9B)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) .:l>~"I_Q -ll~~SC)... \0.
SIGNATURE ~ .. , .. ..