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COUNT,Qutchess
CITYITOWNWappinaer
~~~~~CRT1368
~G~I~J~Ffl1
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Evan J. Chefalo
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
,Jj/it
{'1
1~/O 'tJ1
L [j SUPPLEMENTAL FILE
FROM THE BRIDE
Dawn M. Feimer
MIDDLE CURRENT SURNAME
~
A FULL NAME
11. A FUll NAME
FIRST
FIRST
"-
N
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Chefalo
(OPTIONAL - SEE REVERSEnS7 72-4326
D SDCIAl SECURITY NUMBER U -
12. RESIDENCE ,New York BDutchess
,STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \AI .
SPECIFyWVapPlnaer
D STREET ADDRES23 Pells Place zIP12590
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
IOPTIONAl - SEE REVERSIA09-60-2~SO
D SOCIAL SECURITY NUMBER U ~
2 RESIDENCE ANew York B. Dutchess
ISTATE) .L. (COUNTY)
C CHECK ONE 0 CITY~U TOWN 0 VILLAGE
~~~mY Wappinaer
D STREET ADDRES~3 Pells Place ZIP 12590
E is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE? iJ YEs""'iJ NO
/)'} /1 9RO
DAY YEAR
iJ YES"tJ NO
tAR 1
YEAR
E. IS RESIDENCE WITHiN LIMiTS OF CITY OR INCORPORATED VillAGE?
13. A AGF71 13.8. DATE OF BIRTH O~ ""0
MONTH DAY
3 A. AGF22
06
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATlotManager
B. TYPE OF INDUSTRY OR BUSINES~astry Garden
15. PLACE OF BIRTrOueens New York
(CITY. STAT~/COUNTRY IF NOT USA)
16. FATHER
A NAMEMathias Feimer
B. COUNTRY OF BIRTLJ S A
17 MOTHER
A MAIDEN NAMEMaria Rodrig'lez
B COUNTRY OF BIRT!U ~ A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
3B. DATE OF BIRTH
4 EMPLOYMENT
A USUAL OCCUPATIONCaroenter
B TYPE OF INDUSTRY OR BUSINESSSelf - Employed
5. PLACE OF BIRTSur1in~on Vermont
(CITY, S ATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME James Chefalo
B COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME Trl'lr.p.y Vp.ttp.r
B. COUNTRY OF BIRTH l J ~ A
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(3) iJ ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID lAST MARRIAGE END? (3) D DIVORCE
(31 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
C. DATE lAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES C 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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES i:J 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
4TH
I, being duly sworn, depose and say, that to the b
as to my right to enter into the m~age state.
21 SIGNATURE OF GROOM ~ L.W (
o 0 1 ST 0 [J
o 0 2ND 0 0
o i:J 3RD 0 0
o 0 4TH 0 0
ledge and belief that the Information I provided IS true and that I declare that no legallm~ment eXists
r--- 22 SIGNATUREOFBRIDE~ 0v'l///n ~Jt
NTNAM ~ ~RREN~ -
DATE 06/27/2002
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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. tate of the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies W in 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
TIME MONTH YEAR MONTH
SEAL SIGNATURE
MA~ING ADDRE~S AM
"-v-I 2u MiddlebUsh R 3-.04 PM 06
STREET ZIP
I CERTIFY THAT I SOlEMNIZEO
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME ANO
PLACE INOICATED
YEAR
28
2002 08
26 2002
10 CIVIL
28 PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B COUNTY _t::i1-50
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
[J CITY OF [] TOWN OF ~ILLAGE OF
Ol..
LJ o.AA ~; \.A
SPECIFY
;A-sS3
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
SIGNATURE ~