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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Steven A. Solomon
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies witH 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)Gloria J. M~rse TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATJl8/09/2002
'-y-I ~I~td'a'e in er Falls NY 12590 9:59 ~~ 8 10 2002 10 08 2002
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
~~~~~~ /
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 IV'RELlGIOUS
DATE AND AT THE TIME AND A
PLACE INDICATED. ;2 ';~C> 2(7')2 9 0 OTHER. SPECIFY
COUNT..,Qutchess
CITYfTOWNWappinQer
~~J~~~'1368
~5~I~J~~ 26
1 A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
<l.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERS' 57-48-4321
D. SOCIAL SECURITY NUMBER
2. RESIDENCE ANew York B Dutchess
(STATE) .JJ. (COUNTY)
C. CHECK ONE 0 CITY""D TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRES~2 0 Chelsea Ridne Drive ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE~D NO
Al6 ~970
DAY YEAR
3 A. AG132
3B. DATE OF BIRTH
07
MONTH
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4. EMPLOYMENT
A. USUAL OCCUPATIONPUblicist
B. TYPE OF INDUSTRY OR BUSINES~ender / Helper Impact
5 PLACE OF BIRTilMnaston", New Jersey
(CITY:'!;TATElCOUNTRY IF NOT USA)
6. FATHER
A. NAMEAllen Solomon
B. COUNTRY OF BIRnU S A
7. MOTHER
A. MAIDEN NAME Regina Am
B. COUNTRY OF BIRTHU S A
B. NUMBER OF THIS MARRIAGE'l
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
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
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1ST
2ND
3RD
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21 SIGNATURE OF GROOM ~
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29. OFFICIANT <I" /')(.1 ;1' 'c
NAME (PRINT) 11", . <:, . .,
SIGNATURE ~ /~'
MAI~DDRE S~
;) I -C.R r / t
STREET
30. WITNESS TO CEREMONY
NAME(PRINT)~ s~;;:?
SIGNATURE~ ~
DOH-98 (11/9B)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
/1
~ ~l fJ di1'
I
C.
I)'}
{/J;Jt /
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica A. Costello
MIDDLE CURRENT SURNAME
..J
11 A FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Costello Solom on
(OPTIONAL. SEE REVERSEJ..52 72-4863
D. SOCIAL SECURITY NUMBER U -
12. RESIDENCE ,New York BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 'ti TOWN 0 VILLAGE
~~~CIF.wappinaer
D. STREET ADDRES32 0 Chelsea Ridge Drive
ZIP12590
o YES"tJ NO
1474
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGr27 13.B. DATE OF BIRTH 11 Ail
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIONTeacher
B. TYPE OF INDUSTRY OR BUSINEsArlington Central School
15. PLACE OF BIRnBrookfvnL New York
(CITY, S'ifff/<eOUNTRY IF NOT USA)
16. FATHER
A. NAMEKevin Costello
B. COUNTRY OF BIRTLJ S A
17. MOTHER
A. MAIDEN NAMESh~ron Pantone
B. COUNTRY OF BIRTLJ ~ A
18. NUMBER OF THIS MARRIAGE '1
19. 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
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
1ST
2ND
3RD
4TH
t the information I provided is true and that I declare that
y
22. SIGNATURE OF BRIDE
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY !Je..t-dtfLg;
C. LOCATION OF CEREMONY
(CHJCK ONE AND SPECIFY)
ctVCITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY PD U-~ ~ Ft.tp5; 2.--
TITLE !:i\;<, ("Pc!< ?I-;~+
, I
DATE ?jlo/24.FL-
IIJ. 'I /t.!;?(
, STATE .
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~