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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Dane 0 I Dell
MIDDLE CURRENT SURNAME
15T 0 0 15T 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of m. y knowledge and belief that the information I provided i9-4r:5{d that .1 declare thaZ legal impediment exists
as to my right to enter into the marriage state. j..... ( .
21 SIGNATURE OF GROOM ~ '~. ~ 22. SIGNATURE OF BRIDE ~ .~l L
s CURRENT NAM .. USE CURRENT NAME
23 SUBSCRIBED AND SWORN TO BEFORE ME . OS/21/2002
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 !j11 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 CL~RK 25. A SOLEMNIZATION PERIOD BEGINS
la
COUNTY Dutchess
CITY/TOWN Wappinger
~~~~~CRT 1368
~~~'~~~R 65
A FULL NAME
FIRST
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSElt::73 95 6858
o SOCIAL SECURITY NUMBER :J - -
2 RESIDENCE A. CA B. Alameda
(STATEj (COUNTY)
C CHECK ONE 0 CITY 't"J TOWN 0 VILLAGE
~~~CIFY Livermore
D STREET ADDRESS 714 Alden Lane ZIP 94550
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE' 0 YES'6 NO
OR /10 / 1977
MONTH OA Y YEAR
3 A. AGE24
3B. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Student/ Cadet
B TYPE OF INDUSTRY OR BUSINESS U SMA
PLACE OF BIRTH Livermore, California
(CITY. STATE/COUNTRY IF NOT USA)
6 FATHER
A. NAME Frankie Ray 0 I Dell
B. COUNTRY OF BIRTH USA
7 MOTHER
A MAIDEN NAME Cedlle Ann Phillips
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 DID lAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH OAY YEAR
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
ffi
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{ } NAME (PRINT
SEAL SIGNATU";; ~
'-y-I M~L~'M~8~~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.
RELIGIOUS
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
(\
W"''v'O~
I
,;1tl1t
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Karen M. Reda
~
11 A. FULL NAME
FIRST
MIDOLE
CURRENT SURNAME
B BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE 0 I Dell
(OPTIONAL. SEE REVERSEi051 64 5202
D SDCIAL SECURITY NUMBER --
12 RESIDENCEA.N Y B Dutchess
(STATE) J (COUNTY)
C CHECK ONE 0 CITY D TOWN 0 VILLAGE
~~~CIFY WappinQer
D STREET ADDRESS 7 Lawn Place ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE' 0 YES ri NO
13. A AGE ?5 13.8. DATE OF BIRTH 10 /28 /1976
MONTH OA Y YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Secretarial
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTH Bronx, New York
(CITY. STATE/COUNTRY IF NOT USAj
16. FATHER
A. NAME Dominick J. Reda
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Paulette M. Goldschmitt
B COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8. HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(31 [J ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. 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
TIME
MONTH
YEAR
DATE OS/21/2002
d, W ppinQer Falls, NY 12590
CITYTOWN STATE
27 TYPE OF CEREMONY
10:24 AM 05
PM
ZIP
2B. PLACE WHERE MARRIAGE OCCURRED
~IVIL
A. STATE NEW YORK B COUNTY OIifi"'9 t
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 1f TOWN OF 0 VILLAGE OF
SPECIFylf(~4IYn {4//5
NAME (PRINT)
SIGNATURE ~