087
>-
z
W
Cf)
W
'"
o
...J
:::J
o
I
Cf)
Z
o
>=
..:
a:
>-
Cf)
a
W
a:
W
Cl
..:
a:
a:
..:
::;;
LL
o
W
>-
..:
II
u:
>=
a:
W
II
W
a:
W
I
~
Cf)
Cf)
W
a:
o
o
..:
>-
LL
(3
W
a.
Cf)
Zi.z
!5!::Q W
iii~~ ....
a:~N ~
t;~~ ~
:::JllW ()
~~g u:
z-
G~~ ~
[EOCf) a:
0>->- W
w~(5 ()
b~U1
Z::i~
a.
N
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Lance C. Van Tassell
MIDDLE CURRENT SURNAME
1 ST D D 1 ST D D
2ND D D 2ND D D
3RD D D 3RD D D
4TH D D 4TH D D
I, being duly sworn, depose and say, that to the best of my knowledge 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 m~. ~ . 11 0 ~ _ C}
21. SIGNATURE OF GROOM ~ C. v-- . . 22. SIGNATURE OF BRIDE ~ J;{)()J!..R ~W ~
USE CURRENT N M , USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME 06/25/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
,,-'-.. 24. TOWN OR CITY CLEflK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glon J.
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 06/25/2002
'-,-I M~~GIOfl~dr~bush Rd, . NY 12590 03:25~~ 06 26 200 08 24 2002
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.
COUNTY Dutchess
CITYfTOWN WappinQer
~~~~~rJ 1368
~5~~J~R 87
1 A. FULL NAME
FIRST
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 059-64 5945
D. SDCIAL SECURITY NUMBER -
2 RESIDENCE A. New York B. Dutchess
(ST~Tj) (COUNTY)
C CHECK ONE I'II'J CITY D TOWN D VILLAGE
~~~CIFY Poughkeepsie
D STREET ADDRESS 12 Edgar street ZIP 12603
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? t1 YES D NO
01 / 10 / 197
MONTfl DAY YEAR
3. A. AGE 24
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Security Officer
B. TYPE OF INDUSTRY OR BUSINESS Wackenhut Corp.
5 PLACE OF BIRTH Poughkeepsie, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Francis G. Van Tassel!
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Elizabeth A. Smith
B COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
YEAR
MONTfl DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTfl. DAY. YEAR) (CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
a:
w
CD
::;
::l
Z
o
z
'"
>-
w
w
a:
>-
<f)
w
C/J
Z
W
()
::::i
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
t t1. (}
~i1t' ,j ..It -jJ I,
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Selene Rosario
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Rosario
c. SURNAME AFTER MARRIAGE Van T assell
(OPTIONAL. SEE REVERSE) 054 74 8432
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. N Y B. Dutchess
(STATE) . (COUNTY)
C. CHECK ONE D CITY cf'TOWN D VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 54 Park Hill Drive ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES ri NO
11 /24 /1974
DAY
11. A. FULL NAME
13. A. AGE 27
13.B. DATE OF BIRTH
MONTfl
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Jewelry Sales
B. TYPE OF INDUSTRY OR BUSINESS Giorgios
15. PLACE OF BIRTH Yonkers, New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Frederick Rosario
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Auguilda Diaz
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 1
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTfl DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTfl. DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
YEAR
YEAR
STATE
27. TYPE OF CEREMONY
oX RELIGIOUS
9 D OTHER. SPECIFY
A. STATE NEW YORK B. COUNTY
DAY
130 AM ~ 3 oz
29. OFFICIANT :2. E: V .J 0 Ii A) "J'\ ,/0 U )j ~
NAME (PRINT) I . ,- \.
SIGNATURE ~ .~ ;t/l '-/~
MAILING ADDRESS . / .
( LjCiO 120uTC s'Z. FISH\(/ '-L
STREET CITYfTOWN
30. WITNESS TO CEREMONY
NAME (PRINT) ,.
2B. PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
Oe.AtJG.r=
TITLE vA's TO (C
DATE <6l~ f 0 Z.
I I
A-J '-f I 'Z '5L t.{
STATE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY I\J Ew w l tJ't>S DR
31.
NAME (PRINT)
SIGNATURE ~