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COLlNTyDutchess
CITY/T'OWN Wappinger
DISTRICT1368
NUMBeR ..
~5~I~J~H63
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ralph J. Cenname
FIRST MIDDLE CURRENT SURNAME
FROM THE BRIDE
Mary Ann Lauricella
FIRST MIDDLE CURRENT SURNAME
(THIS SPACE FOR STATE USE ONL Y)
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SUPPLEMENTAL FILE
11. A. FULL NAME
A FULL NAME
CL
N
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Cenname
(OPTIONAL. SEe ReVERSen64-66-1179
D SOCIAL SECURITY NUMBER U
12 RESIDENCE ANew York BDutchess
(STATE! ..I ICOUNTY!
C CHECK ONE 0 CITY 0 TOWN LJ VILLAGE
~~~CIFyWappinQers Falls
D STREET ADDRES~ Stuart Avenue
ZIP 12590
,,~ YES C NO
1971
YEAR
BIRTH NAME IF DIFFERENT
C SURNAME AFTER MARRIAGE
IOPTIONAL SEe REVERSE125-60-0A02
D SOCIAL SECURITY NUMBER U&f"
2 RESIOENCE ANew York B Dutchess
C CHECK ONE (SUbI CITY 0 TOWN 0 VillAGE (COUNTY)
~~~CIFY Beacon
D STREET ADDRESS2 Angela Court Apt. 3 ZIP 1250B
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE' tJ YES 0 NO
12 /J1 /1964
MONTH DAY YEAR
3 A. AGE37
3B DATE OF BIRTH
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE'
13 A AGE30 13.B. DATE OF BIRTH 08 A8
MONTH DAY
14 EMPLOYMENT
A. USUAL OCCUPATIONDomestic EnQineer
B TYPE OF INDUSTRY OR BUSINESS
15 PLACE OF BIRTrEouahkeeosie, New York
'.CITY, STATE'COUNTRY IF NOT USA)
16. FATHER
A NAMEAlfred Lauricella
B COUNTRY OF BIRT~ S A
17 MOTHER
A. MAIDEN NAME Patricia Tomlin
B COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 2
4 EMPLOYMENT
A USUAL OCCUPATION Carpenter
B TYPE OF INDUSTRY OR BUSINESS West Point
5 PLACE OF BIRTHYonkers, New York
(CITY, STATE COUNTRY IF NOT USA)
6 FATHER
A. NAME Ralph Cenname
B COUNTRY OF BIRTH USA
7 MOTHER
A MAIDEN NAME Joan Mullin
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
B HOW DID lAST MARRIAGE END' (3/ :::J DIVORCE
C DATE lAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) 0 DEATH
19 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
1 0
B, HOW DID LAST MARRIAGE END' (3) ~ DIVORCE (3) D ANNULMENT (2! ::::: DEATH
C. DATE lAST MARRIAGE ENDED? 07 /01 /1993
MONT~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES C NO
DEATH
o
DEATH
o
MONTH DAY
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES :::: NO
YEAR
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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
1ST 0 Q 1ST07f01{199~ Goshen, New York [J t
2ND :::: 0 2ND 0
3RD D 0 3RD n
4TH 0 0 4TH [1
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 g stat ~ c- ;yJ".
21 SIGNATURE OF GROOM . , 22 SIGNATURE OF BRIDE ~ l(r)::1~1 Yt n ' t '/2l/1j':ktl
~RR81f'N
23 ~~Jf-r~~~DO~NT~~~O~RN ~~yBg~~~~E DATE 05/17/2002
This license authorizes the marriage in New York Sta authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies within ew York State THIS LICENSE VALID IN NEW YORK 8T A TE 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) _Glo . . Morse .
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ ' O1\TE05/17/2002
'-y-I ~~~ifdfeseush Rd i CITy~~!alls NYSTA1~590 ZIP 2:38 ~~ 05
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
~~~sM~~~~g\B~VJH6'N PTEHRE 0 rL RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED
LJ
W
C/J
Z
W
()
:J
YEAR
18
2002 07
16 2002
28 PLACE WHERE MAP,RIAGE OCCURRED
1 [J CIVil
A. STATE NEW YORK B. COUNTY f)~IIGs:.
9 D OTHER, SPECIFY
C lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
Q CITY OF ~OWN OF D
VillAGE OF
29 OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH.9B (11/98)