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COUNTY Dutchess
C1TYiTOWN Wappinger
~~~~~CRT 1368
~~~I~~~R 88
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
n8niel A T;::!tt;::! I I I
MIDDLE . CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
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1,1'1'4
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
K;::!ren M Rothschild
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
A FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAMEI. IF DIFFERENT
C SURNAME AFTER MARRIAGE T ;::!tt;::!
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 133-64-5643
12. RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY []I'TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D STREET ADDRESS 4 Hickorv Lane ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
10 /?fi A!=lfifi
MONTH DAY YEAR
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL SEE REVERSE)
D SOCIAL SECURITY NUMBER 134-Sn-S8S3
2 RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 102 Nelson Avenue
ZIP . 12590
eM YES 0 NO
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A. AGE 36 3B. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Correction Officer
B TYPE OF INDUSTRY OR BUSINESS Fishkill Correctional
5. PLACE OF BIRTH Buffalo New York
(CITY. STATEkOUNTRY IF NOT USA)
6. FATHER
A. NAME Daniel Anthony Tatta Ii
B COUNTRY OF BIRTH USA
13 A AGE 31)
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Customer Service
B TYPE OF INDUSTRY OR BUSINESS Home Depot
15. PLACE OF BIRTH Bronxville. New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A NAME Alan Rothschild
B COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME FrectR H;::\mill
B COUNTRY OF BIRTH England
lB. NUMBER OF THIS MARRIAGE 2
7 MOTHER
A MAIDEN NAME I ind::l. FOI Lrnier
B COUNTRY OF BIRTH LJ S A
8 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) dDIVORCE (3) 0 ANNULMENT (210 DEATH
C DATE LAST MARRIAGE ENDED? 11 / 02 / 2000
MONT~ DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? LJ 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 11/02/2000 White Plains. New York
2ND
3RD
ffi
al
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f-
W
W
go
en
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT
C DATE LAST MARRIAGE ENDED? 03/ 26 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? [Y'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
03/?6/1998 Buffalo, New York 0 rf
o 0
o 0
o
['
DEATH
o
DEATH
o
(2) 0 DEATH
1998
YEAR
if
['
w
en
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u
::::i
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 S11 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 CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
la
DATE
06/27/2002
by New York Domestic
~
{ } NAME (PRINT
SEAL SIGNATU';; ..
'-y-I MA~~G~~dr~bus
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
~
29 OFFICIANT
NAME (PRINT)
YEAR
MONTH
YEAR
MONTH
TIME
DATE 06/27/2002
d, W ppinQer Falls, NY 12590 08:51 ~~
CITY,TOWN STATE ZIP
27 TYPE OF CEREMONY
1~
06
28
200
08
26 2002
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY V/), \c ~
C LOCATION OF CEREMONY
(CHECK ONE AND }PECIFY) ~ ......;/
o CITY OF cV'fOWNOF ~'\'Y
SPECIF~ \.LO 1+ jC-<c.. 't.~S ~~
ZIP
31 WITNESS TO C5.lO.EMONY
NAME (PRINT) t;(; ( (r\,
(~ ,n'\;
~l
SIGNATURE ~