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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nicholas P. Romano
Dutchess
COUNTY
wappinger
CITY/TO~~
DISTRICn ,:,til:S
NUMBER
REGISTER14ti
NUMBER
1. A. FULL NAME
FIRST
CURRENT SURNAME
MIDDLE
Q.
N
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE114-62-5079
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE Q CITY D TOWN D VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS I U ::-llonYKIII Road
12590
ZIP
"
YES D NO
/1969
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
/22
DAY
3. A. AGE33
3B. DATE OF BIRTH
01
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Contractor
5. :~::~::I~N~~C:n~~:~:I~~~~~~ cmployea
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas Romano
B. COUNTRY OF BIRTH U ~ A
7. MOTHER
A. MAIDEN NAME Doris TIbbets
B. COUNTRY OF BIRTH USA
~
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVifCE CIVIL A~ULMENT
DEiTH
.,.
B. HOW DID LAST MARRIAGE END? (3) D DIVORto (3) D1~NULMENT 1 fififj DEATH
c. DATE LAST MARRIAGE ENDED? / /
MONTH .;'DA Y YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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, that to the best of my knowle
as to my right to enter into the marriage sta .
21. SIGNATURE OF GROOM ~
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
4tnt
/p.. t7/,' t1 1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Heather Crane
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Romano
(OPTIONAL - SEE REVERSE)090-64-2396
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK Q.Ni'. 0 CITY D TOWN D VILLAGE
AND wapplnger
SPECIFY 70 Stonyklll Road
D. STREET ADDRESS
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES D NO
~3 ,W71
13. A. AGE 30
13.B. DATE OF BIRTH
11
MONTH
DAY
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF IND TRY R I S Romano Contracting
15. PLACE OF BIRTH~ee~s~m,~ew YOrk
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Stephen Crane
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Cheryl Ashburn
B. COUNTRY OF BIRTHU S ~
lB. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DltfRCE CIVIL A~ULMENT
D~TH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
D 1ST D D
D 2ND D D
D 3RD D D
D 4TH D D
d belief that the information I provided is true and that I declare that no legal impediment exists
. SIGNATURE OF BRIDE ~~ ~ CA t1../l..-fl- J
SE CURRENT NA 09/11/2002
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24 TOWN OR C!J:.Y"CLI;RKJ M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) l;jIOna . orse
{SEAL SIGNATURE ~ -- fJ 10:
'-v-I M2trfvtRfambush Rd,
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICAT
w
en
z
w
o
~
ZIP
YEAR
STATE
27. TYPE OF CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
CIVIL
2B. PLACE WHERE MARRIAGE OCCUR~ .
A. STATE NEW YORK B. COUNT (CJ'./.m
C. LOCATION OF CEREMONY
(CHECK ONE AND YECIFY)
D CITY OF cYtOWN OF D
VILLAGE OF
~tS " )::J, LL-
NAME (PRINT)
SIGNATURE ~