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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David Marinaccio
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrTOWN Waooinaer
~~~~~c~ 1368
~G~I~~~R 103
A FULL NAME
FIRST
"-
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)122 66 9259
o SOCIAL SECURITY NUMBER --
2 RESIDENCE ANY B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Pouahkeepsie
o STREET ADDRESS 99 Fulton A ven ue ZIP 12603
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
01 /11 /1967
MONTH DAY YEAR
3 A, AGE 35
3B DATE OF BIRTH
4, EMPLOYMENT
A USUAL OCCUPATION Laborer
B TYPE OF INDUSTRY OR BUSINESS Union Local 1000
5 PLACE OF BIRTH Cold SprinQ, New York
(CITY, STATE/COUNTRY IF NOT USA)
6, FATHER
A NAME Robert Marinaccio
B COUNTRY OF BIRTH USA
7 MOTHER
A, MAIDEN NAME Janet Mellis
B COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B HOW 010 LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(21 0 DEATH
C DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
o 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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
PJI,1it
't- al-f - CJ...
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Meaan M, Bollmann
MIDDLE CURRENT SURNAME
~
11 A, FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Marinaccio
(OPTIONAL' SEE REVERSE) 101 52 5925
0, SOCIAL SECURITY NUMBER --
12 RESIDENCE ANY B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY PouQhkeepsie
0, STREET ADDRESS 99 Fulton Avenue ZIP 12603
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ri NO
13, A AGE 39 13,8. DATE OF BIRTH 04 /21 /1963
MONTH DAY YEAR
14 EMPLOYMENT
A, USUAL OCCUPATION Service Desk Associate
B TYPE OF INDUSTRY OR BUSINESS Home Depot
15 PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
16, FATHER
A NAME John Bollmann, Jr.
8. COUNTRY OF BIRTH USA
17, MOTHER
A MAIDEN NAME Ann P. Frohbose
B COUNTRY OF BIRTHU S A
18 NUMBER OF THIS MARRIAGE 2
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B, HOW DID LAST MARRIAGE END? (3) rC1 DIVORCE (3) 0 ANNULMENT 00 DEATH
C, DATE LAST MARRIAGE ENDED? 06 / 08 / 2 00
MONT'V DAY YEAR
0, 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
06/0812000 KinQston, New York [{
DEATH
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and S
as to my right to enter into the rri
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
o my k,wledge and belief that the information I provide
"
o 0
o 0
o 0
legal impediment exists
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 to perform marriage ceremonies within 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 CU:;RK 25, A, SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glon J
{TIME MONTH
SEAL SIGNATURE '/
'-v-I M"W'M~8~bush Rd 01 :44 ~~ 07
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
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o 0 RELIGIOUS
DATE
07/15/2002
by New York Domestic
YEAR
9 0 OTHER, SPECIFY
1 CY6VIL
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY j) cITc/.,€'5)
" 0"'''''' ~~~ u r!f1:. 0
NAME (PRINT) Fo, E I . ~.vA(.1
SIGNATURE ~ V. f!l fl
MAILING ADDR S
f2} tiCCAllelTf It wAI/;/JL.flf
STREET CITYtTOWN
30 WITNESS TO
DATE
TITLE -:SUjT/C. J.
7!2//0 z.- ~
I I
N- Y
STATE '
C, LOC(lTION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
P .
SPECIFY~' TI5HkilL
fAiO
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
1259D
ZIP
" W,"'" !fii0",
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