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COUNTPutchess
CITY/TOwJ^/appinqer
~~~~~CR1363
~5~'~l~Rf 28
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael P. Grimaldi
FROM THE BRIDE
Jennifer L. Dries
,- STATE FILE NUMBER
I (THIS SPACE FOR STA TE USE ONL YI.
~J7ht!(U ff{~wi
191.919/ ~d ~~/7h
L 0 SUPPLEMENTAL FILE ~
"I
A FULL NAME
11 A FULL NAME
FIRST
MIODLE
CURRENT SURNAME
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME) IF DIFFEREN~ook
C SURNAME AFTER MARRIAGEGrimaldi
(OPTIONAL - SEE REVERSEil>41 13 8234
o SOCIAL SECURITY NUMBER L.. - -
12. RESIDENCE New York BDutchess
C. CHECK ONE (STA~) CITY'tJ TOWN D VILLAGE (COUNTY)
~~~cIFWappinQer
o STREET ADDREs4 Kent Road Apt. 5
CURRENT SURNAME
0-
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL SEE REVERSIl78-58-4441
o SOCIAL SECURITY NUMBER
RESIDENCE ANew York B. Dutchess
C CHECK ONE (STA~) CITyoID TOWN D VILLAGE (COUNTY)
~~~CIFY WappinQer
o STREET ADDRES~ Kent Road Apt - 5
ZlP"12590
D YEifD NO
/1969
YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGa4 13.B. DATE OF BIRTH OR 26
MONTH DAY
ZI~ 2590
D YES"b NO
tilf.7
YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A AG133 3B. DATE OF BIRTH 07 /12
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATIO~ssistant ManaQer
B. TYPE OF INDUSTRY OR BUSINES~ T S Tire
5. PLACE OF BIRTMount Vernon, New York
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A USUAL OCCUPATlorResidential Property Manaaer
B. TYPE OF INDUSTRY OR BUSINES~ P I
15. PLACE OF BIRTtlincolnton, North Carolina
(CITY, STATE/COUNTRY IF NOT USA)
16 FATHER
A. NAMDavid Cook
B. COUNTRY OF BIRM S A
6 FATHER
A. NAMERobert Grimaldi
B. COUNTRY OF BIRTcU S A
7. MOTHER
A MAIDEN NAME Carol I e Vinp.R!':
8. COUNTRY OF BIRTHU S A
8 NUMBER OF THIS MARRIAGE 1
17. MOTHER
A. MAIDEN NAMEtCS7Uko Oi~hi
B. COUNTRY OF BIRTJapan
18. NUMBER OF THIS MARRIAGE 3
19 PREVIOUS MARRIAGES
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3) DIVORCE (3) U ANNULMENT (2) D DEATH B. HOW DID LAST MARRIAGE END? (3l'D DIVORCE (3) D ANNULMENT (2) [-I DEATH
/ / C. DATE LAST MARRIAGE ENDED? 04 /06 Aooo
MONTH DAY YEAR MON])! DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO D. ARE ANY FORMER SPOUSE(S) ALIVE? LI YES D 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 (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST D D 1ST01Jn~/199~ r,p.orgia [] ""=1
2ND D D 2Ndl4/06/2000 Pensacola, Florida '6 [J
3RD D [] 3RD LJ ::1
4TH n D 4TH D :J
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true a d that I declare that no Jw:aLLmpediment exists
as to my right to enter into the mar. ge stie..c - , / , ~
21 SIGNATURE OF GROOM ~ ,~ . 22. SIGNATURE OF BRIDE. / '.,<. ~ .;', /
S E CU RENT NAME
DEATH
o
DEATH
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C DATE LAST MARRIAGE ENDED?
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23 SU.8SCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S 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.
D 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 25 B ~~6~MA~~~~,~~i~~D
{ .. } NAM.E (PRINT).~IOr" . M ~A TIME MONTH DAY YEAR MONTH DAY
SEAL;41(]NA~R~,. DATJ08!09/2002
, MAILING Ai1l~R!,SS AM
~ s~,gEtJliddrebush Rd ~JoEalls NYST~T~590 ZIP 1:25 PM 8 '10 2002 10 08 2002
I CHlTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
T~ MARRIAGE OF THE PER.
so~s NAfI.1Eb ABOVE ON THE TIME MO. DA Y YEAR 0 0 RELIGIOUS
Qt,TE AND. AT :V-IE TIME AND
PLACE INDIl;ATED . '.', . 9 0 OTHER, SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
CIVIL
A. STATE NEW YORK B. COUNTY
TITLE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF D VILLAGE OF
~- OFF;c'~T.'i~;~l
N~E(~;L:;~';'''. ','_
SIGNi\T\JRE'~"'f6?;;' ./
MAILlNrl ADDRESS "
'C, ('(
STREET -. CITY/TOWN
30. WITNESS TO CEREMONY
DATE
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE.
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~