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COUNTY Dutchess
CITYITO~~ '!Y~PPlnger
B~~~~CRT I ~"ju
REGISTER 154
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard A. Panessa, JR.
MIDDLE CURRENT SURNAME
CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
OfJrLtI /t.~~ -!;{
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Patricia A. Me Donald
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
MIDDLE
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Panessa
(OPTIONAL. SEE REVERSEI089_66_7628
o SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York B. Dutchess
(STM (COUNTY)
C. CHECK ONE CITY 0 TOWN 0 VILLAGE
~~~CIFY Pougn eepsle
D. STREET ADDRESS~U 10 Soum Koao F 8
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEll03-5D-27!;3
D. SOCIAL SECURITY NUMBER ~
2 RESIDENCE A. New York B Dutchess
(Sl4\!E) (COUNTY)
C. CHECK ONE P CITY D. TOWN 0 VILLAGE
~~~CIFY Pougnkeepsle
D. STREET ADDRESS l f1 U !::)ourn Hoaa r Ci
1 ZbU1
ZIP
vf
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
07 /18 /1957
DAY
1 L6D'1
ZIP
....
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
,Al5
3. A AGE45
13.8. DATE OF BIRTH
os
YES 0 NO
)963
YEAR
13. A. AGE 39
3B. DATE OF BIRTH
MONTH
YEAR
MONTH
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Shipping & Receiving Forman
5. :~A:Y:~::I~N~~~~g~~~~p~i~r~:~I::~~~:m LImo
(CITY. STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Beautician
;-,tl'dIO one
8. TYPE OF INDLlSrRY OR Bl..ISINE:;S - ..
15. PLACE OF BIRTH Hempsreaa, Long Island
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A NAME Richard Panessa
USA
B. COUNTRY OF BIRTH - - . .
7. MOTHER
A. MAIDEN NAME Shirley Peters
B COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE ~
16. FATHER
A. NAME John Mc Donald
B. COUNTRY OF BIRTHU ~ Po.
17. MOTHER
A. MAIDEN NAM~ Emily Carr
U""A
B. COUNTRY OF BIRTH ;:)
18. NUMBER OF THIS MARRIAGE 1
w
en
z
w
o
:::::i
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL A'1l'ULMENT
. ....
vi'
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (90 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? . 02 / 25 / 19 2 c. DATE LAST MARRIAGE ENDED? / /
MONTIiV DAY YEAR MONTH DAY
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
iMONTI-j..DAY, YEAR) (CITY...STATE/COUNTRY..lf NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1 ST u2/2::t/1992 Pougnkeepsie, ,...ew York c5 0 1 ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and s that to.t e best of my kn~Wle and belief that the Information I provided IS true and that I declare that nD legal Impediment eXists
as to my right to enter Into the na stat . t
21 SIGNATURE OF GROOM ~ / K22. SIGNATURE OF BRIDE ~ faIitr<.O\ a. 111 ~~
URR AME USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME 09/24/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized by New York Domestic
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 CL~RK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glona J. Morse
{"TIME MONTH
SEAL SIGNATURE v DATE 09/24/2002
'-y-I M~M~m ush R~, ppl er Falls, NY 12590 02:14 ~~ 09
STREET ITYfTOWN STATE
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED 9 0 OTHER, SPECIFY
DEdTH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D100RCE CIVIL A~ULMENT
DEbTH
YEAR
YEAR
ZIP
1~
28. PLACE WHERE MARRIAGE OCC~
A. STATE NEW YORK B. COUN :<<:-~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF 0 TOWN OF ~LLAGE ~ J L
SPECIFY Wt+~j'^,.I-6~~~
TO C MON
NAME (PRINT) ~/~ 5-. .6 A \:)~A ^"
SIGNATURE~ ~ ~
DOH.98 (11/98)
,
NAME (PRINT)