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COUNTyQutchess
CITY/TOWN WappinQer
~~~~~CRT1368
~~~I~J~P94
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert M. Viviano, JR.
CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
i~t
7 /'1 ,'1
, Co " t).1)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
MarQaret M. Kelly
MIDDLE CURRENT SURNAME
--.J
A FULL NAME
11. A FULL NAME
FIRST
FIRST
MIDDLE
B BiRTH NAME, IF DIFFERENT
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Viviano
(OPTIONAL. SEE REVERSE it 15-50-5352
0, SOCIAL SECURITY NUMBER I
12 RESIDENCE ,New York BDutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIF.pouQhkeepsie
o STREET ADDRES~11 Sheafe Road
ZIP12590
o YES'tJ NO
~56
YEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE.I '12-42 0251
0, SOCIAL SECURITY NUMBER I -
2 RESIDENCE ANew York B Dutchess
(STATE) ..L. ICOUNTY)
C CHECK ONE 0 CITYLJ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRES~ 11 Sheafe Road ZIP 12590
E is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? C YES"'D NO
/03 /'1950
DAY YEAR
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A, AGE45 13,B DATE OF BIRTH 08 /17
MONTH DAY
3 A
AGQ1
01
MONTH
3B, DATE OF BIRTH
14, EMPLOYMENT
A, USUAL OCCUPATIOr--Operator
B, TYPE OF INDUSTRY OR BUSINES~hiIliDS
15, PLACE OF BIRT~anhattan. New York
(CITY, STATE/COUNTRY IF NOT USA)
4, EMPLOYMENT
A, USUAL OCCUPATION Letler Carner
B TYPE OF INDUSTRY OR BUSINESSU S Post Office
5, PLACE OF BIRTHYonkers. New York
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A, NAME Robert Viviano M. Sf.
B COUNTRY OF BIRTHU S A
16, FATHER
A NAMEDaniel Kellv
B COUNTRY OF BIRTAJ S A
17, MOTHER
A, MAIDEN NAMECP-r.p-li~ 1 JIImfln
B COUNTRY OF BIRTlJ S A
18, NUMBER OF THIS MARRIAGE 2
7 MOTHER
A, MAIDEN NAME AnnR r.iRmp.i
B, COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE 2
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9, PREVIOUS MARRIAGES 19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
1 0 0 1 0
B HOW DID LAST MARRIAGE END? {3(0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B, HOW DID LAST MARRIAGE END? (3)'tJ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 03 /23 /2000 C DATE LAST MARRIAGE ENDED? 11 /02 /1995
MON!jl DAY YEAR MON~ DAY YEAR
D ARE ANY FORMER SPOUSE{S) ALIVE? TI YES 0 NO D, ARE ANY FORMER SPOUSE{S) ALIVE? DYES 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 (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
18T03/23/2000 Goshen, New York 'tJ 0 18T11/02/199!l Poughkeep!';ip., Np.w York t"l 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I. being duly sworn, depose an ,the best of ry k_nowled.ge and belief that the InformatIOn I provided IS true and that I declare that no legal Impediment eXists
as to my right to enter into the ,\
21 SIGNATURE OF GROOM ~ ' - 22 SIGNATURE OF BRIDE ~.~- ~..... ^:t1Y) "11.&,~
CUR T NAME ~RENT NAME
23 ~~;..fT~~~Do~Nfo~O~RN ~~yBg~~~~E DATE 01/0 2002
This license authorizes the marriage ate of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit n 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) Glori Morse
TIME YEAR MONTH
SEAL SIGNATURE ~ - DATE:01/01/2002
'-v-' ~~I~ta~~~ush Rd er Falls NY 12590 1.-15 ~~
STREET C YITOWN STATE
~~~R~I:~R;~~~ 10~O~~~N~EE~ 26 SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO DA ,YEAR RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATE
DEATH
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YEAR
2002 08
30 2002
ZIP
l~L
28, PLACE WHERE MARRIAGE OCCUR~ .
A, STATE NEW YORK B COUN 7G/fr1$
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OTHER, SPECIFY
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) L
o CITY OF C TOWN OF L: VILLA~, 11_
SPECIFY vJJ4P/1 ~i<& LM'P
NAME (PRINT) ..
SIGNATURE ~ -.
DOH.98 (11198)
NAME (PRINT)
SIGNATURE ~- .