060
STATE OF NEW YORK I STATE FILE NUMBER I
] COUNT-,Qutchess (THIS SPACE FOR STATE USE ONL Yj
CITY/TOWN Wappinger DEPARTMENT OF HEALTH [}e1t t 7)h'-V1~
~~~~~CRT1368 AFFIDA VIT, LICENSE and
~5~'~J~P(i0 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
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A FULL NAME
FROM THE GROOM
Ronald L. Cantor
II. A. FULL NAME
FROM THE BRIDE
Diane R. Ellison
FIRST
MIDDLE
CURRENT SURNAME
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B BIRTH NAME. IF DIFFERENT
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTMaratto
C. SURNAME AFTER MARRIAGE Ellison - Cantor
(OPTIONAL. SEE REVERSE"84-38-9974
D. SOCIAL SECURITY NUMBER U
12. RESIDENCE ,New York BDutchess
(STATE) ,COUNTYI
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~ClFyWappinQer
D. STREET ADDRESl2 Channinaville Road
ZlP12590
o YES"'!'J NO
1#41
YEAR
CURRENT SURNAME
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSIft74-54-4373
o SOCIAL SECURITY NUMBER U
2 RESIDENCE ANew York B Dutchess
(STATEI ~ (COUNTY)
C CHECK ONE C CITY-U TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRES~2 Channinaville Road ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' ::J YEs"'D NO
Ao A951
DAY YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE'
13 A. AGF54 13.B. DATE OF BIRTH 10 A4
MONTH DAY
3 A. AGM
3B. DATE OF BIRTH
12
MONTH
4 EMPLOYMENT
A. USUAL OCCUPATION Auto Parts
B. TYPE OF INDUSTRY OR BUSINESsMeife Auto Parts
PLACE OF BIRT8ronx New York
(CITY. StATE/COUNTRY IF NOT USA)
6 FATHER
A. NAME Howard Cantor
B COUNTRY OF BIRTHU S A
14. EMPLOYMENT
A. USUAL OCCuPATlot-Hair Stylist
B. TYPE OF INDUSTRY OR BUSINEs4Javide Salon
15. PLACE OF BIRn-White Plains. New York
(CITY, STATE/COUNTHY IF NOT USA)
16. FATHER
A. NAM~alph Maratlo
B. COUNTRY OF BIRTW S A
7. MOTHER
A. MAIDEN NAME Rn~smnnn ~hst~nff
B COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 1
17. MOTHER
A. MAIDEN NAMENl'dalie PSI 110
B COUNTRY OF BIRTIJ S A
18. NUMBER OF THIS MARRIAGE 2
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (210 DEATH B. HOW DID LAST MARRIAGE END? (3)'6 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
/ / C DATE LAST MARRIAGE ENDED? 11 /13 /1980
MONTH DAY YEAR MONT~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? LJ YES 0 NO
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
o 0 1 ST 11 11 :\/19Rfl I S!': Vsgs":. Np.vsns ~ r:?,
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ ~. ~
USE CURRENT NAME
DEATH
o
DEATH
o
C DATE LAST MARRIAGE ENDED?
1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa
as to my right to enter into the nage
21 SIGNATURE OF GROOM
DATE 05/15/2002
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yor named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies . hin 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 J.
TIME MONTH DAY YEAR MONTH
SEAL SIGNATURE
MAILING AD S AM
"-v-I 20 Middlebush Rd 1',32 PM 05
STREET liP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
YEAR
2002 07
16
14 2002
28. PLACE WHERE MARRIAGE OCCURRED
CCURRED
DAY YEAR o~ RELIGIOUS
),.. 7 f) '/ 0.1. 90 OTHER, SPECIFY
~~~tf~~I~~T ~e0 re~/lJ J', ~c,eL{je~ TITLE 11711lJ1STe--16
SIGNATURE ~. ,~\' ),.Q,.",D ,J-c~~1~ DATE.La '}. ~b
M,ILlNG ADDRE ~ . (/ ~ . .
/9D $0.(-/1.. P1l1rrJiL/Ldl tVew~rc. h !by /:;'),)'0
STREET CITYiTOWN 't' "STATE
30. WITNESS TO CE'iEMONY
10 CIVIL
A. STATE NEWYORK B. COUNTyOcffcftf"5S
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
[2' CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY r? h ,r;e becK- I "J.... ')'7')...
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
31.