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C0U'NTY Dutchess
CITYfTOWN Wappinger
~~J~~crJ 1368
~5~~J~R 134
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT; LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert W Sko"n~1ru
MIDDLE . CURRE~IT SURNAME
I
"I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
D4zt
Cf~;4t'~t'R
L D SUPPLEMENTAL FILE
FROM THE BRIDE
~hri~tinp A . ronp.~
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULlNAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT ,
C. SURNAME AFTER MARRIAGE Skolin~1<y ,
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 1 ~? -n4-04 ?~
12. RESIDENCE A. New Vor\< B. nllt~he~~
ISTAft) lCc5uNTY)
C. CHECK ONE 0 CITY r!!' TOWN 0 VILLAGE
~~CIFY East Fishkill
D. STREET ADDRESS 2191 Route 52 ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES I'!l' NO
13. A. AGE ~~ 13.B. DATE OF BIRTH ()q /28 /'j 966
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 132-44-4526
2. RESIDENCE A. New t ork B. Dutchess
(STAT ) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY East Fishkill
o STREET ADDRESS 32 Marion Avenue
ZIP 12590
DYES r!5 NO
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 49 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Truck Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Town Of East Fishkill
5. PLACE OF BIRTH Yonkers . New York
ICITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Walter Skolinsky
B. COUNTRY OF BIRTH USA
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINESS Carmel Wind Water
15. PLACE OF BIRTH Queens. New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Jones
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME K~thleFm I Ollghlin
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 3
7. MOTHER
A. MAIDEN NAME Mildred Montamallrn
B. COUNTRY OF BIRTH U S A
8. NUMBER OF THIS MARRIAGE 2
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DEATH DIVORCE CIVIL ANNULMENT
1 2 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~ DEATH B. HOW DID LAST MARRIAGE END? (3) r"f DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05 / 31 / 2002 c. DATE LAST MARRIAGE ENDED? 08 / 11 / 1995
MONTH JAY YEAR MONT~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES Ll NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 1..J 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 (MONTIH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 1ST 01/05/1988 Orange County, New York 0 ~
o 2ND 08/11/1995 Delray Beach. Florida 0 ~
o 3RD 0 0
o 4TH 0 0
belief that the information I provided is true ediment exists
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
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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 St bride and groom named above by any
Relations Law ~11 to perform marriage ceremonies withi ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the pur ose of a second or subsequent ceremony.
r-"-.. 24. TOWN OR CITY CLE.RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) _GIO ~ M rs
TIME MONTH
SEAL SIGNATURE ~
'-v-I M~'Mftrcffebush Rd, 01 :35 ~~ 08
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
1,1( CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY.PO 7"'r#.6':(" \
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J:i< TOWN OF 0 VILLAGE OF
SPECIFY u/,I/1,p'p//I/6!-61?
SIGNATURE ~
